Dosage Timing

[was_a_guru]

I have had RLS/PLMD for ~25 years and since 2005 have been taking Ropinerole. Most nights it seems to be pretty effective (there are occasional nights where it is much worse). But I when I get up early in the morning (usually around 5 AM) to urinate often the symptoms start again and I am unable to go back to sleep easily. I currently take 2.5 mg ~3 hours before bedtime.

On several occasions I experimented by taking only 2 mg ~3 hours before bedtime and then -.5 mg at bedtime and that seemed to help with the early morning relapse.

Is that going to cause augmentation, rebound, or any other problem as opposed to taking the 2.5 mg dosage at a single time?

Any advice is welcome. Thanks.

[Yankiwi]

I've had RLS for about 20 years, at least 10 severe and unmedicated so that I was up at least two or more times for over an hour every night doing anything possible to get rid of my leg pain. About 18 months ago I was prescribed Ropinerole, which at first seemed like a miracle. After a few weeks I increased the dosage by one tablet to two (.5mg), then by another half whereby I started to experience augmentation. Luckily for me, at that point I joined the RLS Foundation, found this blog and received advice to cut back. Gradually I cut back to my original dose of one tablet (.25mg) two hours before bed. At bedtime I take one 50mg Tramadol. I can usually sleep for three - five hours. Upon waking up I take another Tramadol, stretch and sit quietly for up to 10-15 minutes then go back to bed. If I wake up again before wanting to be up I do a different stretching/relaxing routine.
This timing of the Ropinerole and Tramadol seems to work for me. I'm wary of RLS medications and prefer getting up several times at night rather than taking enough of anything to get me through the whole night. I don't know how I'll go with the stretching when I'm 90 though and hope something is found by then (about 25 years away).

[Rustsmith]

Based upon the explanation that Dr Allen gave during an RLS Foundation webinar in August 2014, one of the drivers for augmentation is the swings in dopamine concentrations throughout the day as you take the pills and then the DA is metabolized. As you go to increased doses, the highs get higher, but the lows also get lower and it is the lows that drive your symptoms. Therefore, the approach that you are experimenting with might help delay the point where augmentation eventually does drive you off of ropinerole.

If you are interested, the webinar that Dr Allen gave on augmentation was excellent. It, like all other past webinars, is available on the RLS Foundation website, but you have to be a paid up Foundation member to get access.

[ViewsAskew]

Have you always taken this dosage? If you originally took less, you may already have augmentation.

Ropinerole only works for about 5-6 hours, if I remember correctly. So,when you take it 3 hours before bed, it's not surprising that you would have symptoms when you awaken at 5 AM, if bedtime is around 10-11 PM and you took it around 8 PM.

You already have found that you have more success taking it in divided doses - and that makes sense. You might find that you could split it into 3 doses and even take less. This definitely addresses the highs and lows Steve mentioned (which may actually protect you some from augmentation) and gives you coverage for longer.

Another option, if you have always taken this dose and augmentation is a potential current issue, would be to switch to a dopamine agonist that is delivered evenly throughout the day. Rotogotine is delivered via a patch, so you have constant protection and coverage - no highs and lows and considered to have a much lower risk of augmentation.

All that said, while swings may be one factor (and may be the most important one), some people seem more prone to it that others, regardless of dose. I augmented on only .125 mg of pramipexole - and in only one week. We know that ferritin levels are important, as people with ferritin under 100 have a tendency to augment much more frequently.

[Polar Bear]

My RLS symptoms are pretty much 24/7 and were thus even before I started medication (ropinerole and tramadol/codeine).
I space my ropinerole dosage across the 24 hours. Less in the morning, a little more at 1pm, more at 5pm and 9pm, with a lesser dose at around 3am.
This works for me, supplemented with SR tramadol morning and evening.
Any other breakthrough is dealt with by a 30/500 cocodamol.