Augmentation

[Rustsmith]

The link below that was prepared by badnights will take you to a discussion of Augmentation that also includes link to many other Augmentation resources.

viewtopic.php?f=5&t=6532&p=61601#p61601

[tagalongbuddy]

I had been on pramipexole for a few years, then ropinirole for five more years. (higher than maximum dose) I didn't think I would ever be able to get off these pills. I saw a new neurologist a few months ago who has experience with RLS patients. I am following the protocol exactly as he told me. He had me very slowly go off the ropinirole and slowly add on gabapentin. The final week of ropinirole was difficult but that was the worst of it. He told me to take one gabapentin (300 mg) in morning, 600 mg at 7pm (with dinner) then 45 minutes before bedtime take four gabapentin (1,200 mg)
I am now able to sleep MUCH better and what is amazing to me is: I am not having RLS symptoms!!!! My husband and I are both astounded! I will not discontinue the gabapentin until the neurologist says to do so. There is hope.

[Polar Bear]

tagalongbuddy - I was in the same position as yourself. Taking higher than the maximum dose of ropinirole, was augmented and needed to get off it.
I was also taking prescribed Codeine but the Codeine wasn't sufficient to fight the augmentation. My ropinirole dose was 5mg total daily.
I did it much the same as yourself but used Pregabalin. My Pregabalin equated pretty much to your dosage of Gabapentin. They are similar drugs. However, I also had the benefit of taking Codeine. I don't know how long you took to reduce your ropinirole but I took about ten months, did it really slowly and managed without much difficulty.

Yes, you can indeed come off ropinirole, many here have done it, albeit much quicker than I did.
Well done. I am very happy to hear that you are sleeping well. Your dosage of gabapentin is doing it's job,

[Belsheart]

Finished my pramipexole taper at long last a couple of nights ago. Naturally, I’m getting almost no sleep. Would love encouraging words.

[Belsheart]

Just adding to my post. A couple of years ago I tried to get totally off pramipexole, and I did lower my dose to .0125. But stopped due to withdrawal. That bought me some time. Once I felt augmentation symptoms, I knew I had to finish it. I kept splitting that little pill until completely off. The worst withdrawal symptom is the involuntary leg jumps. Really can’t sit still at night. Hope my body bounces back soon. I take 600 mg of gabapentin. No opioids due to other heart and blood pressure issues. Definitely want to hear Stories of things getting better. Oh, getting iron checked this week

[bratbomb]

I have been on ropinirole HCL for about three years and Tramadol for about two years. I feel like the Tramadol isn't working for me so I have quit it cold turkey about 6 days ago. I am still taking 1mg of ropinirole X five tablets a day. I am going crazy right now! The ropinirole is not working at all right now and I am getting very little sleep a night (if any). I am thinking it is from weening off of Tramadal cold turkey. Can anyone please give me some suggestions as what to do for some relief! I am thinking about going back on the Tramadol just because I don't know what to do

[badnights]

I have been on ropinirole HCL for about three years and Tramadol for about two years. I feel like the Tramadol isn't working for me so I have quit it cold turkey about 6 days ago. I am still taking 1mg of ropinirole X five tablets a day. I am going crazy right now! The ropinirole is not working at all right now and I am getting very little sleep a night (if any). I am thinking it is from weening off of Tramadal cold turkey. Can anyone please give me some suggestions as what to do for some relief! I am thinking about going back on the Tramadol just because I don't know what to do

It's possible that you felt the tramadol wasn't working because you've augmented on ropinirole. If that's the case, nothing will seem to work until you can get off the ropinirole and stay off a couple of weeks. (That will give your internal dopamine system time to re-set). It's also quite possible that your symptoms are worse right now because of tramadol withdrawal, which will last 4-10 days in most people. (see here for a list of common withdrawal symptoms).

So re-starting the tramadol and tapering off it might help you. But ultimately - and preferably sooner than later - you will need to stop the ropinirole. The tramadol might help after the ropinirole withdrawal is over (but it might not be strong enough during ropinirole withdrawal).

I don't advise stopping the ropinirole until you have a plan for how to control the symptoms, or a plan for how to live with them (e.g. take time off work and have someone drop off meals and walk the dog) because withdrawal from a DA (dopamine agonist, like ropinirole) consists of brutal WED/RLS symptoms and generally no sleep at all for a number of days. It would be best to stop the ropinirole with a physician in your corner. Stopping such a high (for WED/RLS) dose as 5 mg might require a taper. Some people have tapered down over months; others have gone cold turkey, but going cold turkey from 5 mg is not usually advised, because it might increase the chances of experiencing additional withdrawal symptoms other than the inevitable WED/RLS symptoms. Be aware, though, that it's important to keep the entire taper period as short as possible, to keep the period of suffering brutal WED/RLS as short as possible (a point that most doctors don't understand).

To prepare for the withdrawal, it would be nice if you could get an iron infusion (if your transferrin saturation is less than 45% and your serum ferritin is under 100). Iron is now regarded as the first thing a doctor should check in a patient with WED/RLS, and often, iron by itself can fix the WED/RLS symptoms without any other medication, if the disease has not been augmented by a DA.

After iron, the first-recommended medications for WED/RLS are alpha-2-delta ligands (gabapentin, pregabalin, Horizant). These medications are never effective enough to treat symptoms during DA withdrawal. Usually, the only medication that can help during DA withdrawal is an opioid. After the withdrawal is over, an alpha-2-delta might work on its own but most likely you will need that plus an opioid or tramadol. The combination would allow you to use a lower dose of each than if you were taking either one alone.

But the trick will be getting a physician on board with you. Who has prescribed you the 5 mg of ropinirole? Whoever it was doesn't keep up to date on how to treat this disease. Even as long ago as 2012, some specialists recommended no more than 1 mg, and the latest advice from the American Academy of Sleep Medicine in 2025 says ropinirole should not be used in WED/RLS at all, unless all other methods are not tolerated.

You might want to save whatever tramadol you haven't taken the last few days, and any more you save during a later taper, to use if necessary after the withdrawal is over to get a good night's sleep now and then while you try to find a physician who will prescribe what you need. Hopefully that won't be necessary, though.

There are papers in my signature link that you could show your doctor - the 2018 Opioid recommendations, the 2018 Iron recommendations, and if you are or could become a member of the RLS Foundation, the brochures explaining what augmentation is.

Let us know what you decide, and if I can clarify any of this, let me know!

[badnights]

Just adding to my post. A couple of years ago I tried to get totally off pramipexole, and I did lower my dose to .0125. But stopped due to withdrawal. That bought me some time. Once I felt augmentation symptoms, I knew I had to finish it. I kept splitting that little pill until completely off. The worst withdrawal symptom is the involuntary leg jumps. Really can’t sit still at night. Hope my body bounces back soon. I take 600 mg of gabapentin. No opioids due to other heart and blood pressure issues. Definitely want to hear Stories of things getting better. Oh, getting iron checked this week

Wish I'd seen this back in 2021 to give you a big hug of encouragement!