In a 62‑year‑old patient with restless‑legs syndrome who has been taking 4 mg extended‑release ropinirole for four years and also nightly 800 mg gabapentin for fibromyalgia and sleep difficulties, should the recommendation to taper and discontinue ropinirole remain the same?

Recommendation for Tapering Ropinirole in a Patient Already Taking Gabapentin

Yes, the recommendation to taper and discontinue ropinirole remains the same—and is actually strengthened—because this patient is already taking 800 mg gabapentin nightly, which provides a therapeutic foundation for transitioning away from the dopamine agonist. 1

Why the Recommendation Remains Unchanged

• The 2025 American Academy of Sleep Medicine guidelines issue a conditional recommendation against the standard use of ropinirole (moderate certainty of evidence) due to a 7–10% annual risk of augmentation—a paradoxical worsening characterized by earlier symptom onset, increased intensity, and spread to the arms or trunk. 1

• Alpha-2-delta ligands (gabapentin, gabapentin enacarbil, pregabalin) are now strongly recommended as first-line therapy for RLS (strong recommendation, moderate certainty of evidence), representing a major shift from older guidelines that listed dopamine agonists as first-line agents. 1

• After four years of ropinirole use, this patient faces cumulative augmentation risk of approximately 28–40%, making discontinuation medically prudent even if current symptoms appear controlled. 1

Advantages of Pre-Existing Gabapentin Therapy

• This patient already has an established alpha-2-delta ligand on board, which simplifies the transition strategy compared to patients starting from scratch. 1

• Gabapentin 800 mg nightly is being used for fibromyalgia and sleep, but it also provides RLS coverage—though the current dosing regimen (single nighttime dose) is suboptimal for 24-hour RLS symptom control. 1

• The American Academy of Sleep Medicine recommends gabapentin dosing starting at 300 mg three times daily (900 mg/day total) and titrating up to 1800–2400 mg/day divided TID for optimal RLS management, rather than single nighttime dosing. 1

Optimized Transition Strategy

Step 1: Optimize Gabapentin Dosing Before Tapering Ropinirole

• Redistribute the existing 800 mg gabapentin from once-nightly to a divided schedule (e.g., 300 mg morning, 300 mg afternoon, 200 mg bedtime) to provide daytime RLS coverage and address the fibromyalgia pain throughout the day. 1

• If symptoms are not adequately controlled after 3–7 days, increase gabapentin by 300 mg/day every few days until reaching the recommended maintenance dose of 1800–2400 mg/day divided three times daily. 1

• Single nighttime dosing fails to address daytime RLS symptoms and provides suboptimal 24-hour neuropathic pain coverage for fibromyalgia. 1

Step 2: Assess and Optimize Iron Status

• Check morning fasting serum ferritin and transferrin saturation after withholding iron supplements for ≥24 hours before finalizing the taper plan. 1

• If ferritin ≤75 ng/mL or transferrin saturation <20%, add oral ferrous sulfate 325–650 mg daily (or every other day to improve tolerability) or consider IV ferric carboxymaltose 750–1000 mg for rapid correction. 1

• Iron repletion can significantly improve RLS symptoms independent of gabapentin and may reduce the total gabapentin dose ultimately required. 1

Step 3: Taper Ropinirole Very Slowly

• Once adequate symptom control is achieved with optimized gabapentin dosing (and iron supplementation if indicated), reduce ropinirole by 0.25–0.5 mg every 1–2 weeks. 1

• The FDA-approved titration schedule for ropinirole (starting at 0.25 mg nightly and escalating to 4 mg daily) predates the 2025 AASM guideline evidence of high augmentation risk; consequently, current guidelines now recommend against its standard use. 1

• Anticipate rebound RLS and insomnia during the taper; temporary use of immediate-release ropinirole or carbidopa/levodopa may serve as bridge therapy but should be discontinued once transition is complete. 1

• Do not increase the ropinirole dose if symptoms worsen during the taper, as this likely reflects augmentation rather than inadequate dosing. 1

Step 4: Monitor for Augmentation Signs

• Watch for earlier onset of symptoms during the day (afternoon instead of evening), increased intensity, spread to the arms or trunk, and paradoxical worsening despite ongoing therapy. 1

• The need for rescue medications such as immediate-release dopamine agonist, carbidopa/levodopa, or sedative agents (e.g., trazodone) signals that the extended-release formulation is no longer effective and reflects classic augmentation patterns. 1

Alternative Alpha-2-Delta Ligand: Pregabalin

• Pregabalin is another strongly recommended first-line option (strong recommendation, moderate certainty of evidence) that allows twice-daily dosing and may have superior bioavailability compared to regular gabapentin. 1

• Recommended initial dose is 50 mg TID or 75 mg BID; after 3–7 days, increase to 300 mg/day, then by 150 mg every 3–7 days as tolerated, up to a maximum of 600 mg/day. 1

• Switching from gabapentin to pregabalin may be considered if the patient experiences inadequate symptom control or intolerable side effects (dizziness, somnolence) with gabapentin. 1

Addressing Fibromyalgia and Sleep Comorbidities

• As alpha-2-delta ligands can alleviate chronic pain and may be helpful in treating anxiety and insomnia, the presence of fibromyalgia and sleep difficulties actually favors the use of gabapentin or pregabalin over dopamine agonists. 2

• Optimizing gabapentin dosing to 1800–2400 mg/day divided TID will likely provide superior fibromyalgia pain control compared to the current 800 mg nightly regimen. 1

• Insomnia is present in roughly 90% of people with RLS and is the primary morbidity; addressing RLS with alpha-2-delta ligands rather than dopamine agonists improves both RLS symptoms and sleep quality. 1

Critical Pitfalls to Avoid

• Do not continue ropinirole indefinitely simply because symptoms appear controlled; after four years of use, augmentation risk is substantial and may manifest suddenly. 1

• Do not rely on trazodone or other sedatives as primary RLS therapy; they only treat sleep disturbance, not the underlying RLS pathology. 1

• Do not use clonazepam as monotherapy for RLS; it provides only sedation without reducing periodic limb movements and carries risks of hepatotoxicity and teratogenicity. 1

• Do not assume that 800 mg gabapentin nightly is an adequate RLS dose; the evidence supports 1800–2400 mg/day divided TID for optimal symptom control. 1

Monitoring and Follow-Up

• Reassess RLS severity with the International RLS Study Group Rating Scale at 4–6 weeks after completing the ropinirole taper. 1

• Repeat iron studies every 6–12 months, as brain iron deficiency may persist despite clinical improvement. 1

• Evaluate both nighttime symptom relief and daytime functional outcomes (alertness, mood, quality of life, fibromyalgia pain control). 1

• Monitor for side effects of alpha-2-delta ligands, particularly dizziness and somnolence, which are typically transient and mild. 1

If Transition Fails: Refractory RLS Options

• If symptoms remain severe despite optimized gabapentin (1800–2400 mg/day), corrected iron status (ferritin >75 ng/mL, transferrin saturation >20%), and elimination of aggravating factors (caffeine, alcohol, antihistamines, SSRIs), consider extended-release oxycodone 5–10 mg at bedtime (conditional recommendation, moderate certainty of evidence). 1

• Long-term observational data show only modest dose escalation over 2–10 years and a relatively low risk of abuse when patients are appropriately screened. 1

• Alternative low-dose opioids include methadone 5–10 mg daily for 24-hour symptom coverage or buprenorphine (transdermal or sublingual). 1

• Bilateral high-frequency peroneal nerve stimulation receives a conditional recommendation (moderate certainty) as a non-invasive option for patients who refuse or cannot tolerate opioids. 1