Ropinirole Dosing for Parkinson's Disease and Restless Legs Syndrome
Parkinson's Disease
For Parkinson's disease, start ropinirole at 0.25 mg three times daily and titrate weekly according to the FDA-approved schedule, reaching 3 mg/day by week 4, with a maximum dose of 24 mg/day (8 mg three times daily). 1
Initial Titration Schedule (Weeks 1-4)
- Week 1: 0.25 mg three times daily (total 0.75 mg/day) 1
- Week 2: 0.5 mg three times daily (total 1.5 mg/day) 1
- Week 3: 0.75 mg three times daily (total 2.25 mg/day) 1
- Week 4: 1 mg three times daily (total 3 mg/day) 1
Further Dose Escalation
- After Week 4: Increase by 1.5 mg/day weekly up to 9 mg/day 1
- Beyond 9 mg/day: Increase by up to 3 mg/day weekly to maximum 24 mg/day 1
- Doses above 24 mg/day have not been tested in clinical trials 1
Administration Details
- Ropinirole can be taken with or without food 1
- The mean daily dose in clinical trials was approximately 8.7 mg for early therapy and 8.2 mg for adjunct therapy 2
- Ropinirole demonstrates approximately dose-linear pharmacokinetics at steady state 3
Restless Legs Syndrome
For restless legs syndrome, start ropinirole at 0.25 mg once daily 1-3 hours before bedtime, titrating gradually over 7 weeks to a maximum of 4 mg/day—though current guidelines suggest against standard use of ropinirole for RLS due to long-term augmentation risk. 1, 4
Titration Schedule for RLS
- Days 1-2: 0.25 mg once daily before bedtime 1
- Days 3-7: 0.5 mg once daily 1
- Week 2: 1 mg once daily 1
- Week 3: 1.5 mg once daily 1
- Week 4: 2 mg once daily 1
- Week 5: 2.5 mg once daily 1
- Week 6: 3 mg once daily 1
- Week 7: 4 mg once daily (maximum dose) 1
Important Guideline Considerations
- The American Academy of Sleep Medicine suggests against standard use of ropinirole for RLS due to long-term augmentation risk 4
- Ropinirole may only be considered in patients who explicitly prioritize short-term symptom relief over long-term adverse effects 4
- Gabapentin or pregabalin are preferred first-line agents for long-term RLS management 4
- The dosage needed for RLS is much smaller than what is required for Parkinson's disease 5
Renal Impairment Adjustments
Parkinson's Disease
- Moderate impairment (CrCl 30-50 mL/min): No dose adjustment needed 1
- End-stage renal disease on hemodialysis: Start at 0.25 mg three times daily, maximum 18 mg/day total 1
- Supplemental doses after dialysis are not required 1
Restless Legs Syndrome
- Moderate impairment (CrCl 30-50 mL/min): No dose adjustment needed 1
- End-stage renal disease on hemodialysis: Start at 0.25 mg once daily, maximum 3 mg/day 1
- Supplemental doses after dialysis are not required 1
Discontinuation Protocol
Parkinson's Disease
- Taper over 7 days: reduce from three times daily to twice daily for 4 days, then once daily for 3 days before complete withdrawal 1
Restless Legs Syndrome
- Gradual reduction of daily dose is recommended 1
Critical Safety Considerations
Common Adverse Effects
- Parkinson's disease: Nausea, somnolence, leg edema, abdominal pain, vomiting, dyspepsia, and hallucinations are more common than placebo 2
- As adjunct therapy: Dyskinesia, nausea, hallucinations, and confusion are more frequent 2
- Most adverse effects are mild, though hallucinations can occur, particularly in older patients 6
Monitoring Requirements
- Watch for impulse control disorders (pathological gambling, hypersexuality, compulsive shopping), especially at higher doses 4
- Monitor for augmentation in RLS patients (earlier symptom onset, increased intensity, spread to other body parts) 4
- Most adverse experiences decrease with time despite increasing doses, except for hallucinations 2
Retitration After Interruption
- If significant therapy interruption occurs, retitration may be warranted 1