Requip PD

Ropinirole hydrochloride.

Each prolonged release tablet contains ropinirole hydrochloride equivalent to 2, 4 or 8 mg ropinirole (free base).
Excipients/Inactive Ingredients: Tablet cores: Hypromellose 2208, hydrogenated castor oil, carmellose sodium, povidone K29-32, maltodextrin, magnesium stearate, lactose monohydrate, anhydrous colloidal silica, mannitol (E421), ferric oxide yellow (E172), glyceryl dibehenate.
Film Coats: See Table 1.

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ATC Code: N04BC04.
Pharmacology: Pharmacodynamics: Mechanism of Action: Parkinson's disease is characterised by a marked dopamine deficiency in the nigral striatal system. Ropinirole is a non-ergoline D2/D3 dopamine agonist that alleviates this deficiency by stimulating striatal dopamine receptors.
Ropinirole acts in the hypothalamus and pituitary to inhibit the secretion of prolactin.
Clinical efficacy: A 36-week, double-blind, three-period crossover study, in monotherapy with a primary end point of change from period baseline in Unified Parkinson's Disease Rating Scale (UPDRS) total motor score was conducted in 161 patients with early phase Parkinson's disease. A subgroup analysis of patients initiated on monotherapy treatment with ropinirole immediate release tablets and switched overnight to the nearest equivalent dose of ropinirole prolonged-release tablets was consistent with similar efficacy from equivalent mg for mg doses. The adjusted mean difference between ropinirole prolonged-release tablets and Requip film-coated (immediate-release) tablets at study-endpoint was 0.7 points (95% CI: [-1.51, 0.10], p=0.0842).
Following the overnight switch to a similar dose of the alternative tablet formulation, there was no difference in the adverse event profile and less than 3% of patients required a dose adjustment (all dose adjustments were increases by one dose level. No patients required a dose increase).
A 24-week, double-blind, placebo-controlled, parallel group study in patients with Parkinson's disease who were not optimally controlled on levodopa demonstrated that adjunctive therapy of ropinirole prolonged-release tablets results in clinically relevant and statistically significant superiority over placebo in a change from baseline in awake time "off" (adjusted mean treatment difference -1.7 hours (95% CI: [-2.34, -1.09], p<0.0001). This was supported by secondary efficacy parameters of change from baseline in total awake time "on" (+1.7 hours (95% CI [1.06, 2.33], p<0.0001) and total awake time "on" without troublesome dyskinesias (+1.5 hours (95% CI: [0.85, 2.13], p<0.0001). Importantly, there was no indication of an increase from baseline in awake time "on" with troublesome dyskinesias, either from diary card data or from the UPDRS items.
Study of the effect of ropinirole on cardiac repolarisation: A thorough QT study conducted in male and female healthy volunteers who received doses of 0.5, 1, 2 and 4 mg of ropinirole film-coated (immediate release) tablets once daily showed a maximum increase of the QT interval duration at the 1 mg dose of 3.46 milliseconds (point estimate) as compared to placebo. The upper bound of the one sided 95% confidence interval for the largest mean effect was less than 7.5 milliseconds. The effect of ropinirole at higher doses has not been systematically evaluated.
The available clinical data from a thorough QT study do not indicate a risk of QT prolongation at doses of ropinirole up to 4 mg/day. A risk of QT prolongation cannot be excluded as a thorough QT study at doses up to 24 mg/day has not been conducted.
Pharmacokinetics: Absorption: Bioavailability of ropinirole is approximately 50% (36 to 57%). Following oral administration of ropinirole PR, plasma concentrations increase slowly, with a median time to C_max of between 6 and 10 hours.
In a steady-state study in Parkinson's disease patients receiving 12 mg of ropinirole PR once daily, a high fat meal increased the systemic exposure to ropinirole as shown by an average 20% increase in AUC (90% CI [1.12, 1.28]) and an average 44% increase in C_max (90% CI [1.34, 1.56]). T_max was delayed by 3.0 hours. However, in the studies that established the safety and efficacy of ropinirole PR, patients were instructed to take study medication without regard to food intake.
The system exposure to ropinirole is comparable for ropinirole prolonged-release tablets and ropinirole film-coated (immediate-release) tablets based on the same daily dose.
Distribution: Plasma protein binding of the drug is low (10 to 40%). Consistent with its high lipophilicity, ropinirole exhibits a large volume of distribution (approx. 7 L/kg).
Biotransformation: Ropinirole is primarily cleared by CYP1A2 metabolism and its metabolites are mainly excreted in the urine. The major metabolite is at least 100 times less potent than ropinirole in animal models of dopaminergic function.
Elimination: Ropinirole is cleared from the systemic circulation with an average elimination half-life of about 6 hours. The increase in systemic exposure (C_max and AUC) to ropinirole is approximately proportional over the therapeutic dose range. No change in the oral clearance of ropinirole is observed following single and repeated oral administration. Wide inter-individual variability in the pharmacokinetic parameters has been observed. Following steady-state administration of ropinirole prolonged-release tablets, the inter-individual variability of C_max was between 30% and 55% and for AUC was between 40% and 70%.
Special Patient Populations: Renal Impairment: There was no change observed in the pharmacokinetics of ropinirole in Parkinson's disease patients with mild to moderate renal impairment.
In patients with end stage renal disease receiving regular dialysis, oral clearance of ropinirole is reduced by approximately 30%. Oral clearance of the metabolites SKF-104557 and SKF-89124 were also reduced by approximately 80% and 60%, respectively. Therefore, the recommended maximum dose is limited to 18 mg/day in these patients with Parkinson's disease.
Toxicology: Preclinical safety data: Reproductive toxicity: In fertility studies in female rats, effects were seen on implantation due to the prolactin-lowering effect of ropinirole. It should be noted that prolactin is not essential for implantation in humans.
Administration of ropinirole to pregnant rats at maternally toxic doses resulted in decreased foetal body weight at 60 mg/kg/day (approximately twice the highest AUC at the maximum recommended human dose [MRHD]), increased foetal death at 90 mg/kg/day (mean AUC in rats is approximately 3 times the highest AUC at the MRHD) and digit malformations at 150 mg/kg/day (approximately 5 times the highest AUC at the MRHD). There were no teratogenic effects in the rat at 120 mg/kg/day (approximately 4 times the highest AUC at the MRHD) and no indication of an effect during organogenesis in the rabbit when given alone at 20 mg/kg (9.5 times the mean human C_max at the MRHD). However, ropinirole at 10 mg/kg (4.8 times the mean human C_max at the MRHD) administered to rabbits in combination with oral L-dopa produced a higher incidence and severity of digit malformations than L-dopa alone.
Toxicology: The toxicology profile is principally determined by the pharmacological activity of ropinirole behavioural changes, hypoprolactinaemia, decrease in blood pressure and heart rate, ptosis and salivation. In the albino rat only, retinal degeneration was observed in a long term study at the highest dose (50 mg/kg/day), and was probably associated with an increased exposure to light.
Genotoxicity: Genotoxicity was not observed in a battery of in vitro and in vivo tests.
Carcinogenicity: From two-year studies conducted in the mouse and rat at dosages up to 50 mg/kg there was no evidence of any carcinogenic effect in the mouse. In the rat, the only drug-related lesions were Leydig cell hyperplasia and testicular adenoma resulting from the hypoprolactinaemic effect of ropinirole. These lesions are considered to be a species specific phenomenon and do not constitute a hazard with regard to the clinical use of ropinirole.
Safety pharmacology: In vitro studies have shown that ropinirole inhibits hERG-mediated currents. The IC₅₀ is 5-fold higher than the expected maximum plasma concentration in patients treated at the highest recommended dose (24 mg/day), see Pharmacodynamics as previously mentioned.

Treatment of Parkinson's disease under the following conditions: Initial treatment as monotherapy, in order to delay the introduction of levodopa; In combination with levodopa, over the course of the disease, when the effect of levodopa wears off or becomes inconsistent and fluctuations in the therapeutic effect occur ("end of dose" or "on-off" type fluctuations).

Oral use.
Individual dose titration against efficacy and tolerability is recommended. REQUIP PD prolonged-release tablets should be taken once a day, at a similar time each day. The tablets must be swallowed whole and must not be chewed, crushed or divided.
The prolonged-release tablets may be taken with or without food. A high fat meal may double the AUC and C_max in some individuals (see Pharmacology: Pharmacokinetics under Actions).
Adults: Initial titration: The starting dose of ropinirole prolonged-release tablets is 2 mg once daily for the first week; this should be increased to 4 mg once daily from the second week of treatment. A therapeutic response may be seen at a dose of 4 mg once daily of ropinirole prolonged-release tablets.
Patients who initiate treatment with a dose of 2 mg/day of ropinirole prolonged-release tablets and who experience side effects that they cannot tolerate, may benefit from switching to treatment with ropinirole film-coated (immediate release) tablets at a lower daily dose, divided into three equal doses.
Therapeutic regimen: Patients should be maintained on the lowest dose of ropinirole prolonged-release tablets that achieve symptomatic control.
If sufficient symptomatic control is not achieved or maintained at a dose of 4 mg once daily of ropinirole prolonged release tablets, the daily dose may be increased by 2 mg at weekly or longer intervals up to a dose of 8 mg once daily of ropinirole prolonged-release tablets.
If sufficient symptomatic control is still not achieved or maintained at a dose of 8 mg once daily of ropinirole prolonged-release tablets, the daily dose may be increased by 2 mg to 4 mg at two weekly or longer intervals. The maximum daily dose of ropinirole prolonged-release tablets is 24 mg.
It is recommended that patients are prescribed the minimum number of ropinirole prolonged-release tablets that are necessary to achieve the required dose by utilising the highest available strengths of ropinirole prolonged-release tablets.
When REQUIP PD prolonged-release tablets are administered as adjunct therapy to levodopa, it may be possible to reduce gradually the levodopa dose, depending on the clinical response. In clinical trials, the levodopa dose was reduced gradually by approximately 30% in patients receiving REQUIP PD prolonged-release tablets concurrently. In patients with advanced Parkinson's disease receiving REQUIP PD prolonged-release tablets in combination treatment with levodopa, dyskinesias can occur during the initial titration of REQUIP PD prolonged-release tablets. In clinical trials it was shown that a reduction of the L-dopa dose may ameliorate dyskinesia (see Adverse Reactions).
When switching treatment from another dopamine agonist to ropinirole, the marketing authorisation holder's guidance on discontinuation should be followed before initiating ropinirole.
As with other dopamine agonists, it is necessary to discontinue ropinirole treatment gradually by reducing the daily dose over the period of one week (see Precautions).
Switching from REQUIP (immediate-release) tablets to REQUIP PD (prolonged-release) tablets: Patients may be switched overnight from REQUIP (immediate-release) tablets to REQUIP PD prolonged-release tablets.
The dose of REQUIP PD prolonged-release tablets should be based on the total daily dose of REQUIP (immediate-release) tablets that the patient was taking. The recommended dose for switching from REQUIP (immediate-release) tablets to REQUIP PD prolonged-release tablets are provided in the following table. If patients are taking a different total daily dose of REQUIP (immediate-release) tablets to those typically prescribed doses as shown in the table, they should be switched to the nearest available dose of REQUIP PD prolonged-release tablets as stated in the table: See Table 2.

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After switching to REQUIP PD prolonged-release tablets, the dose may be adjusted depending on the therapeutic response (see Initial titration and Therapeutic regimen as previously mentioned).
Dose interruption or discontinuation: If treatment is interrupted for one day or more, re-initiation by dose titration on REQUIP (immediate-release) tablets should be considered.
If it is necessary to discontinue ropinirole treatment, this should be done gradually by reducing the daily dose over the period of one week.
Renal Impairment: In parkinsonian patients with mild to moderate renal impairment (creatinine clearance between 30 and 50 mL/min) no change in the clearance of ropinirole was observed, indicating that no dosage adjustment is necessary in this population.
A study into the use of ropinirole in patients with end stage renal disease (patients on haemodialysis) has shown that a dose adjustment in these patients is required as follows: The recommended initial dose of REQUIP PD is 2 mg once daily. Further dose escalations should be based on tolerability and efficacy. The recommended maximum dose is 18 mg/day in patients receiving regular dialysis. Supplemental doses after dialysis are not required.
The use of ropinirole in patients with severe renal impairment (creatinine clearance less than 30 ml/min) without regular haemodialysis has not been studied.
Hepatic Impairment: The use of ropinirole in patients with hepatic impairment has not been studied. Administration of ropinirole to such patients is not recommended.
Elderly: The clearance of ropinirole is decreased by approximately 15% in patients aged 65 years or above. Although a dose adjustment is not required, ropinirole dose should be individually titrated, with careful monitoring of tolerability, to the optimal clinical response. In patients aged 75 years and above, slower titration during treatment initiation may be considered.
Children and adolescents: REQUIP PD prolonged-release tablets are not recommended for use in children below 18 years of age due to a lack of data on safety and efficacy.

The symptoms of ropinirole overdose are generally related to its dopaminergic activity. These symptoms may be alleviated by appropriate treatment with dopamine antagonists such as neuroleptics or metoclopramide.

Hypersensitivity to ropinirole or to any of the excipients.
Severe renal impairment (creatinine clearance <30ml/min) without regular haemodialysis.
Hepatic impairment.

Due to the risk of hypotension, blood pressure monitoring is recommended, particularly at the start of treatment, in patients with severe cardiovascular disease (in particular coronary insufficiency).
Patients with a history or presence of major psychotic disorders should only be treated with dopamine agonists if the potential benefits outweigh the risks (see also Interactions).
Impulse control disorders: Patients should be regularly monitored for the development of impulse control disorders. Patients and carers should be made aware that behavioural symptoms of impulse control disorders including pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including REQUIP PD. Dose reduction/tapered discontinuation should be considered if such symptoms develop. Impulse control disorders were reported especially at high doses and were generally reversible upon reduction of the dose or treatment discontinuation. Risk factors such as a history of compulsive behaviours were present in some cases (see Adverse Reactions).
Ropinirole has been associated with somnolence and episodes of sudden sleep onset, particularly in patients with Parkinson's disease. Sudden onset of sleep during daily activities, in some cases without awareness or warning signs, has been reported (see Adverse Reactions). Patients must be informed of this and advised to exercise caution while driving or operating machines during treatment with ropinirole. Patients who have experienced somnolence and/or an episode of sudden sleep onset must refrain from driving or operating machines. Furthermore, a reduction of dosage or termination of therapy may be considered.
Neuroleptic malignant syndrome: Symptoms suggestive of neuroleptic malignant syndrome have been reported with abrupt withdrawal of dopaminergic therapy. Therefore it is recommended to taper treatment (see Dosage & Administration).
REQUIP PD tablets are designed to release medication over a 24hr period. If rapid gastrointestinal transit occurs, there may be risk of incomplete release of medication, and of medication residue being passed in the stool.
Dopamine agonist withdrawal syndrome: To discontinue treatment in patients with Parkinson's disease, ropinirole should be tapered off (see Dosage & Administration). Non-motor adverse effects may occur when tapering or discontinuing dopamine agonists including ropinirole. Symptoms include apathy, anxiety, depression, fatigue, sweating and pain which may be severe. Patients should be informed about this before tapering the dopamine agonist, and monitored regularly thereafter. In case of persistent symptoms, it may be necessary to increase the ropinirole dose temporarily (see Adverse Reactions).
Hallucinations: Hallucinations are known as a side effect of treatment with dopamine agonists and levodopa. Patients should be informed that hallucinations can occur.
Excipients: This medicinal product also contains lactose. Patients with rare hereditary problems of galactose intolerance, the Lapp lactase deficiency or glucose-galactose malabsorption should not take this medicine.
REQUIP PD 4mg tablets contained the azo colouring agent sunset yellow (E110), which may cause allergic reactions.
Effects on Ability to Drive and Use Machines: Ropinirole may have a major effect on the ability to drive and use machines.
Patients being treated with ropinirole and presenting with somnolence and/or sudden sleep episodes must be informed to refrain from driving or engaging in activities where impaired alertness may put themselves or others at risk of serious injury or death (e.g. operating machines) until such recurrent episodes and somnolence have resolved (see Impulse control disorders as previously mentioned).

Pregnancy: There are no adequate data from the use of ropinirole in pregnant women. Studies in animals have shown reproductive toxicity (see Pharmacology: Toxicology: Preclinical safety data under Actions). As the potential risk for humans is unknown, it is recommended that ropinirole is not used during pregnancy unless the potential benefit to the patient outweighs the potential risk to the foetus.
Lactation: Ropinirole-related material was shown to transfer into the milk of lactating rats. It is unknown whether ropinirole and its metabolites are excreted in human milk. A risk to the suckling child cannot be excluded.
Ropinirole should not be used in nursing mothers as it may inhibit lactation.
Fertility: There are no data on the effects of ropinirole on human fertility. In female fertility studies in rats, effects were seen on implantation but no effects were seen on male fertility (see Pharmacology: Toxicology: Preclinical safety data under Actions).

Adverse events are listed as follows by system organ class and frequency. Frequencies are defined as: very common (≥1/10), common (≥1/100, <1/10), uncommon (≥1/1,000, <1/100), rare (≥1/10,000, <1/1,000), very rare (<1/10,000), including isolated reports.
During clinical trials, the most commonly reported adverse events for REQUIP PD prolonged release tablets were during monotherapy and dyskinesia during adjunctive therapy with levedopa.
The following adverse events were reported during clinical trials with REQUIP PD up to 24 mg / day. (See Table 3.)

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In addition to the previously mentioned adverse events, the following events have been reported with REQUIP (immediate-release) tablets in patient during clinical trials (at doses up to 24 mg / day) and / or post-marketing reports. (See Table 4.)

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Dopamine agonist withdrawal syndrome: Non-motor adverse effects may occur when tapering or discontinuing dopamine agonists including ropinirole (see Precautions).
Impulse control disorders: Pathological gambling, increased libido, hypersexuality, compulsive spending or buying, binge eating and compulsive eating can occur in patients treated with dopamine agonists including REQUIP PD (see Precautions).

There is no pharmacokinetic interaction between ropinirole and L-dopa or domperidone which would necessitate dosage adjustment of these drugs. Neuroleptics and other centrally active dopamine antagonists, such as sulpiride or metoclopramide, may diminish the effectiveness of ropinirole and, therefore, concomitant use of these drugs should be avoided.
Ropinirole is principally metabolised by the cytochrome P450 enzyme CYP1A2. A pharmacokinetic study (with a REQUIP (immediate-release) tablet dose of 2 mg, three times a day) in Parkinson's disease patients, revealed that ciprofloxacin increased the C_max and AUC of ropinirole by 60% and 84% respectively, with a potential risk of adverse events. Hence, in patients already receiving REQUIP PD, the dose of REQUIP PD may need to be adjusted when drugs known to inhibit CYP1A2, e.g. ciprofloxacin, enoxacin, cimetidine or fluvoxamine, are introduced or withdrawn.
A pharmacokinetic interaction study in Parkinson's patients between ropinirole (with a REQUIP (immediate-release) tablet dose of 2 mg, three times a day) and theophylline, a substrate of CYP1A2, revealed no change in the pharmacokinetics of either ropinirole or theophylline.
Increased plasma concentrations of ropinirole have been observed in patients treated with high doses of oestrogens. In patients already receiving hormone replacement therapy (HRT), REQUIP PD treatment may be initiated in the normal manner. However, if HRT is stopped or introduced during treatment with ropinirole, dosage adjustment may be required.
Smoking is known to induce CYP1A2 metabolism, therefore if patients stop or start smoking during treatment with REQUIP PD, adjustment of dose may be required.

Antiparkinsonian Drugs

N04BC04 - ropinirole ; Belongs to the class of dopamine agonist. Used in the management of Parkinson's disease.

P₁S₁S₃