From the FDA Drug Label
Patients with Renal Impairment: Based on population pharmacokinetic analysis, no difference was observed in the pharmacokinetics of ropinirole in subjects with moderate renal impairment (creatinine clearance between 30 to 50 mL/min) compared with an age-matched population with creatinine clearance above 50 mL/min Therefore, no dosage adjustment is necessary in patients with moderate renal impairment. A trial of ropinirole in subjects with end-stage renal disease on hemodialysis has shown that clearance of ropinirole was reduced by approximately 30%. The recommended maximum dose is lower in these patients [see Dosage and Administration (2.2. 3)]. The use of ropinirole in subjects with severe renal impairment (creatinine clearance <30 mL/min) without regular dialysis has not been studied.
Ropinirole use in AKI context:
- Moderate renal impairment: No dosage adjustment is necessary.
- Severe renal impairment: The use of ropinirole has not been studied.
- End-stage renal disease on hemodialysis: A reduced maximum dose is recommended. Ropinirole can be used in patients with moderate renal impairment without dose adjustment, but its use in severe renal impairment or AKI without regular dialysis has not been studied, and therefore, cannot be recommended. In patients with end-stage renal disease on hemodialysis, a reduced maximum dose is recommended 1.
From the Research
Ropinirole can be used in patients with acute kidney injury (AKI), but dose adjustment is recommended to minimize the risk of adverse effects. For patients with AKI, the initial dose should be reduced to 0.25 mg three times daily, with slower titration based on clinical response and tolerability 2. The maximum daily dose should generally not exceed 9 mg in patients with significant kidney impairment, compared to the standard maximum of 24 mg daily in patients with normal renal function. Close monitoring for side effects is essential, as ropinirole and its metabolites are primarily excreted by the kidneys, and impaired renal function can lead to drug accumulation. Common side effects to watch for include nausea, dizziness, somnolence, and orthostatic hypotension, which may be more pronounced in patients with kidney dysfunction.
Key Considerations
- Reduced kidney function decreases the clearance of ropinirole, potentially leading to higher blood levels and increased risk of adverse effects 3, 4.
- AKI management in critical care settings is challenging, including appropriate volume control, nephrotoxic drug management, and the timing and type of kidney support 3.
- The optimal timing of renal replacement therapy in critically ill patients with AKI is unclear, but is an area of active investigation 4.
- Even one episode of AKI increases the risk of cardiovascular disease, chronic kidney disease, and death, making early determination of etiology, management, and long-term follow-up of AKI essential 5.
Monitoring and Dose Adjustment
- Close monitoring of serum creatinine and urine output is necessary to assess the severity of AKI and adjust the dose of ropinirole accordingly 6.
- If the patient's AKI is severe or worsening, consider temporarily holding the medication or consulting with a nephrologist for personalized dosing guidance 2.
- Fluid management should aim for early, rapid restoration of circulatory volume, but should be more limited after the first 24-48 h to avoid volume overload 6.