Ropinirole Hydrochloride (ropinirole hydrochloride 2 mg) Dailymed

Recent Major Changes Section

Dosage and Administration (2.2, 2.3)    8/2014

Contraindications (4)   8/2014

Warnings and Precautions (5.5, 5.7)   8/2014

1 Indications And Usage

Ropinirole extended-release tablets are a, non-ergoline dopamine agonist indicated for the treatment of Parkinson’s disease. (1.1)

1.1 Parkinsons Disease

Ropinirole extended-release tablets are indicated for the treatment of Parkinson’s disease.

2 Dosage And Administration

• •Ropinirole extended-release tablets are taken once daily, with or without food; tablets must be swallowed whole and must not be chewed, crushed, or divided. (2.1)
• •The recommended starting dose is 2 mg taken once daily for 1 to 2 weeks; the dose should be increased by 2 mg/day at one week or longer intervals; the maximum dose is 24 mg/day (2.2, 14.2)
• •Renal Impairment: In patients with end-stage renal disease on hemodialysis, the maximum recommended dose is 18 mg/day (2.2)
• •If ropinirole extended-release tablets must be discontinued, it should be tapered gradually over a 7-day period; retitration of ropinirole extended-release tablets may be warranted if therapy is interrupted (2.1, 2.2)
• •Patients may be switched directly from immediate-release ropinirole to ropinirole extended-release tablets; the initial switching dose of ropinirole extended-release tablets should most closely match the total daily dose of immediate-release ropinirole (2.3)

2.1 General Dosing Recommendations

• •Ropinirole extended-release tablets are taken once daily, with or without food [see Clinical Pharmacology (12.3)].
• •Tablets must be swallowed whole and must not be chewed, crushed, or divided.
• •If a significant interruption in therapy with ropinirole extended-release tablets has occurred, retitration of therapy may be warranted.

2.2 Dosing for Parkinsons Disease

The starting dose is 2 mg taken once daily for 1 to 2 weeks, followed by increases of 2 mg/day at one week or longer intervals as appropriate, based on therapeutic response and tolerability. The maximum recommended dose of ropinirole extended-release tablets is 24 mg/day.

In clinical trials, dosage was initiated at 2 mg/day and gradually titrated based on individual patient therapeutic response and tolerability. Doses greater than 24 mg/day have not been studied in clinical trials. Patients should be assessed for therapeutic response and tolerability at a minimal interval of one week or longer after each dose increment. Monitor patients during dose titration because too rapid a rate of titration may lead to dose selection that may not provide additional benefit, but that may increase the risk of adverse reactions [see Clinical Studies (14.2)]. Due to the flexible dosing design used in clinical trials, specific dose-response information could not be determined.

Ropinirole extended-release tablets should be discontinued gradually over a 7-day period.

No dose adjustment is necessary in patients with moderate renal impairment (creatinine clearance of 30 to 50 mL/min). The recommended initial dose of ropinirole extended-release tablets for patients with end-stage renal disease on hemodialysis is 2 mg once daily. Further dose escalations should be based on tolerability and need for efficacy. The recommended maximum total daily dose is 18 mg/day in patients receiving regular dialysis. Supplemental doses after dialysis are not required. The use of ropinirole extended-release tablets in patients with severe renal impairment without regular dialysis has not been studied.

2.3 Switching from Immediate-release Ropinirole Tablets to Ropinirole Extended-release Tablets

Patients may be switched directly from immediate-release ropinirole to ropinirole extended-release tablets. The initial dose of ropinirole extended-release tablets should most closely match the total daily dose of the immediate-release formulation of ropinirole, as shown in Table 1.

Table 1: Conversion from Immediate-release Ropinirole to Extended-release Ropinirole

Immediate-release Ropinirole Tablets Total Daily Dose (mg)	Ropinirole Extended-release Tablets Total Daily Dose (mg)
0.75 to 2.25	2
3 to 4.5	4
6	6
7.5 to 9	8
12	12
15	16
18	18
21	20
24	24

Following conversion to ropinirole extended-release tablets, the dose may be adjusted depending on therapeutic response and tolerability [see Dosage and Administration (2.2)].

2.4Effect of Gastrointestinal Transit Time on Medication Release

Ropinirole extended-release tablets are designed to release medication over a 24-hour period. If rapid gastrointestinal transit occurs, there may be risk of incomplete release of medication and medication residue being passed in the stool.

• •Sudden onset of sleep and somnolence may occur (5.1)
• •Syncope may occur (5.2)
• •Hypotension, including orthostatic hypotension may occur (5.3)
• •Elevation of blood pressure and changes in heart rate may occur (5.4)
• •May cause hallucinations and psychotic-like behaviors (5.5)
• •May cause or exacerbate dyskinesia (5.6)
• •May cause problems with impulse control or compulsive behaviors (5.7)

5.1 Falling Asleep during Activities of Daily Living and Somnolence

Patients treated with ropinirole have reported falling asleep while engaged in activities of daily living, including driving or operating machinery, which sometimes resulted in accidents. Although many of these patients reported somnolence while on ropinirole, some perceived that they had no warning signs such as excessive drowsiness, and believed that they were alert immediately prior to the event. Some have reported these events more than one year after initiation of treatment.

Among the 613 patients who received ropinirole extended-release in clinical trials, there were five cases of sudden onset of sleep and two cases of motor vehicle accident in which it is not known if falling asleep was a contributing factor.

During the 6-month trial in advanced Parkinson’s disease, somnolence was reported in 7% of patients receiving ropinirole extended-release compared with 4% of patients receiving placebo. During the 36-week trial in early Parkinson’s disease, somnolence was reported in 11% of patients receiving ropinirole extended-release compared with 15% of patients receiving the immediate-release formulation of ropinirole [see Adverse Reactions (6.1)]. However, because dose-response was not systematically studied with ropinirole extended-release, the occurrence of somnolence at the highest recommended doses may be higher than these reported frequencies [see Adverse Reactions (6.1)].

It has been reported that falling asleep while engaged in activities of daily living usually occurs in a setting of preexisting somnolence, although patients may not give such a history. For this reason, prescribers should reassess patients for drowsiness or sleepiness, especially since some of the events occur well after the start of treatment. Prescribers should also be aware that patients may not acknowledge drowsiness or sleepiness until directly questioned about drowsiness or sleepiness during specific activities.

Before initiating treatment with ropinirole extended-release, patients should be advised of the potential to develop drowsiness and specifically asked about factors that may increase the risk with ropinirole extended-release such as concomitant sedating medications, the presence of sleep disorders, and concomitant medications that increase ropinirole plasma levels (e.g., ciprofloxacin) [see Drug Interactions (7.1)]. If a patient develops significant daytime sleepiness or episodes of falling asleep during activities that require active participation (e.g., driving a motor vehicle, conversations, eating), ropinirole extended-release should ordinarily be discontinued [see Dosage and Administration (2.2)]. If a decision is made to continue ropinirole extended-release, patients should be advised to not drive and to avoid other potentially dangerous activities. There is insufficient information to establish that dose reduction will eliminate episodes of falling asleep while engaged in activities of daily living.

5.2Syncope

Syncope, sometimes associated with bradycardia, was observed in association with ropinirole extended-release in Parkinson’s disease patients. In a placebo-controlled trial involving patients with advanced Parkinson’s disease, syncope occurred in 2 of the 202 patients (1%) who received ropinirole extended-release and in none of the 191 patients who received placebo [see Adverse Reactions (6.1)].

Because the trial of ropinirole extended-release excluded patients with significant cardiovascular disease, patients with significant cardiovascular disease should be treated with caution.

5.3Hypotension/Orthostatic Hypotension

Dopamine agonists in clinical trials and clinical experience appear to impair the systemic regulation of blood pressure, with resulting orthostatic hypotension, especially during dose escalation. In addition, patients with Parkinson’s disease appear to have an impaired capacity to respond to a postural challenge. For these reasons, patients should be monitored for signs and symptoms of orthostatic hypotension, especially during dose escalation, and patients should be informed of the risk for syncope and hypotension [see Patient Counseling Information (17)].

In a placebo-controlled trial involving patients with advanced Parkinson’s disease, hypotension was reported as an adverse event in 5 of 202 patients (2%) receiving ropinirole extended-release and in none of the 191 patients receiving placebo. Orthostatic hypotension was reported as an adverse event in 5% of patients receiving ropinirole extended-release and in 1% of placebo recipients [see Adverse Reactions (6.1)].

An analysis of the randomized, double-blinded, placebo-controlled trial in advanced Parkinson's disease was conducted using a variety of adverse event terms possibly suggestive of hypotension, including hypotension, orthostatic hypotension, dizziness, vertigo, and blood pressure decreased. This analysis showed a higher incidence of these events with ropinirole extended-release (7%, 15 of 202) vs. placebo (3%, 6 of 191). This increased incidence with ropinirole extended-release tablets was observed in a setting in which patients were very carefully titrated, and patients with clinically relevant cardiovascular disease or symptomatic orthostatic hypotension at baseline had been excluded from this trial.

Orthostatic vital signs (semi-supine to standing) were monitored throughout the advanced Parkinson’s disease trial and changes related to ropinirole extended-release (compared with placebo) from baseline were assessed.

The frequency of orthostatic hypotension at any time during the trial was 38% for ropinirole extended-release vs. 31% for placebo for mild-to-moderate systolic blood pressure decrements (≥ 20 mm Hg), 63% for ropinirole extended-release vs. 58% for placebo for mild-to-moderate diastolic blood pressure decrements (≥ 10 mm Hg), 10% for ropinirole extended-release vs. 7% for placebo for severe diastolic blood pressure decrements (≥ 20 mm Hg), and 23% for ropinirole extended-release vs. 19% for placebo for mild-to-moderate combined systolic and diastolic blood pressure decrements.

Significant decrements in blood pressure unrelated to standing were also reported in some patients taking ropinirole extended-release. In the semi-supine position, the frequency was 10% for ropinirole extended-release vs. 8% for placebo for severe systolic blood pressure decrease (≥ 40 mm Hg), and was 25% for ropinirole extended-release vs. 21% for placebo for severe diastolic blood pressure decrease (≥ 20 mm Hg).

The increased incidence for hypotension and/or orthostatic hypotension was observed in both the titration and maintenance phases and in some cases persisted into the maintenance period after developing in the titration phase.

5.4Elevation of Blood Pressure and Changes in Heart Rate

In the placebo-controlled trial in advanced Parkinson’s disease, there were no clear effects of ropinirole extended-release on average changes in blood pressure or heart rate compared with placebo.

In the semi-supine position, the frequency was 8% for ropinirole extended-release vs. 5% for placebo for severe systolic blood pressure increase (≥ 40 mm Hg). In the standing position, the frequency was 9% for ropinirole extended-release vs. 6% for placebo for severe systolic blood pressure increase (≥ 40 mm Hg). In the semi-supine position, the frequency was 23% for ropinirole extended-release vs. 18% for placebo for moderate pulse increase (≥ 15 beats/minute), and 19% for ropinirole extended-release vs. 17% for placebo for moderate pulse decrease (≥ 15 beats/minute). In the standing position, the frequency was 2% for ropinirole extended-release vs. < 1% for placebo for severe pulse increase (≥ 30 beats/minute), and 24% for ropinirole extended-release vs. 19% for placebo for moderate pulse decrease (≥ 15 beats/minute).

The increased incidence for various elevations of systolic and/or diastolic blood pressure and/or changes in pulse was observed in both the titration and maintenance phases as well as persisting into the maintenance period after developing in the titration phase.

Elevation of blood pressure and/or changes in heart rate in patients taking ropinirole extended-release should be considered when treating patients with cardiovascular disease.

5.5Hallucinations/Psychotic-like Behavior

In the double-blind, placebo-controlled, advanced Parkinson’s disease trial, 8% (17 of 202) of patients receiving ropinirole extended-release reported hallucination compared with 2% (4 of 191) patients receiving placebo [see Adverse Reactions (6.1)]. Hallucinations led to discontinuation of treatment in 2% (4 of 202) of patients on ropinirole extended-release and 1% (2 of 191) of patients on placebo.

The incidence of hallucination is increased in elderly patients (i.e., older than 65 years) treated with ropinirole extended-release [see Use in Specific Populations (8.5)].

Postmarketing reports indicate that patients may experience new or worsening mental status and behavioral changes, which may be severe, including psychotic-like behavior during treatment with ropinirole or after starting or increasing the dose of ropinirole. Other drugs prescribed to improve the symptoms of Parkinson’s disease can have similar effects on thinking and behavior. This abnormal thinking and behavior can consist of one or more of a variety of manifestations including paranoid ideation, delusions, hallucinations, confusion, psychotic-like behavior, disorientation, aggressive behavior, agitation, and delirium.

Patients with a major psychotic disorder should ordinarily not be treated with ropinirole extended-release because of the risk of exacerbating the psychosis. In addition, certain medications used to treat psychosis may exacerbate the symptoms of Parkinson’s disease and may decrease the effectiveness of ropinirole extended-release [see Drug Interactions (7.3)].

5.6Dyskinesia

Ropinirole extended-release may potentiate the dopaminergic side effects of L-dopa and may cause and/or exacerbate pre-existing dyskinesia in patients treated with L-dopa for Parkinson's disease. In the double-blind, placebo-controlled trial in patients with advanced Parkinson’s disease dyskinesia was reported as an adverse event in 13% of patients taking ropinirole extended-release and 3% of patients on placebo [see Adverse Reactions (6.1)]. Decreasing the dose of the dopaminergic drug may ameliorate this adverse reaction.

5.7Impulse Control/Compulsive Behaviors

Case reports suggest that patients can experience intense urges to gamble, increased sexual urges, intense urges to spend money, binge or compulsive eating, and/or other intense urges, and the inability to control these urges while taking one or more of the medications, including ropinirole extended-release, that increase central dopaminergic tone and that are generally used for the treatment of Parkinson’s disease. In some cases, although not all, these urges were reported to have stopped when the dose was reduced or the medication was discontinued. Because patients may not recognize these behaviors as abnormal, it is important for prescribers to specifically ask patients or their caregivers about the development of new or increased gambling urges, sexual urges, uncontrolled spending, binge or compulsive eating, or other urges while being treated with ropinirole extended-release. Physicians should consider dose reduction or stopping the medication if a patient develops such urges while taking ropinirole extended-release.

5.8Withdrawal-emergent Hyperpyrexia and Confusion

A symptom complex resembling the neuroleptic malignant syndrome (characterized by elevated temperature, muscular rigidity, altered consciousness, and autonomic instability), with no other obvious etiology, has been reported in association with rapid dose reduction, withdrawal of, or changes in dopaminergic therapy. Therefore, it is recommended that the dose be tapered at the end of treatment with ropinirole extended-release as a prophylactic measure [see Dosage and Administration (2.2)].

5.9Melanoma

Epidemiological studies have shown that patients with Parkinson’s disease have a higher risk (2 to approximately 6-fold higher) of developing melanoma than the general population. Whether the increased risk observed was due to Parkinson’s disease or other factors, such as drugs used to treat Parkinson’s disease, is unclear. In the clinical development program (N = 613), one patient treated with ropinirole extended-release and also levodopa/carbidopa developed melanoma.

For the reasons stated above, patients and providers are advised to monitor for melanomas frequently and on a regular basis when using ropinirole extended-release. Ideally, periodic skin examinations should be performed by appropriately qualified individuals (e.g., dermatologists).

5.10Fibrotic Complications

Cases of retroperitoneal fibrosis, pulmonary infiltrates, pleural effusion, pleural thickening, pericarditis, and cardiac valvulopathy have been reported in some patients treated with ergot-derived dopaminergic agents. While these complications may resolve when the drug is discontinued, complete resolution does not always occur.

Although these adverse reactions are believed to be related to the ergoline structure of these compounds, whether other, non-ergot-derived dopamine agonists, such as ropinirole, can cause them is unknown.

Cases of possible fibrotic complications, including pleural effusion, pleural fibrosis, interstitial lung disease, and cardiac valvulopathy have been reported in the development program and postmarketing experience for ropinirole. In the clinical development program (N = 613), two patients treated with ropinirole extended-release had pleural effusion. While the evidence is not sufficient to establish a causal relationship between ropinirole and these fibrotic complications, a contribution of ropinirole cannot be excluded.

5.11Retinal Pathology

Retinal degeneration was observed in albino rats in the 2-year carcinogenicity study at all doses tested (equivalent to 0.6 to 20 times the maximum recommended human dose [MRHD] of 24 mg/day on a mg/m² basis), but was statistically significant at the highest dose (50 mg/kg/day). Retinal degeneration was not observed in a 3 month study in pigmented rats, in a 2-year carcinogenicity study in albino mice, or in 1 year studies in monkeys or albino rats. The significance of this effect for humans has not been established, but involves disruption of a mechanism that is universally present in vertebrates (e.g., disk shedding).

Ocular electroretinogram (ERG) assessments were conducted during a 2-year, double-blind, multicenter, flexible-dose, L-dopa-controlled clinical trial of immediate-release ropinirole in patients with Parkinson’s disease; 156 patients (78 on immediate-release ropinirole, mean dose:

11.9 mg/day and 78 on L-dopa, mean dose: 555.2 mg/day) were evaluated for evidence of retinal dysfunction through electroretinograms. There was no clinically meaningful difference between the treatment groups in retinal function over the duration of the trial.

5.12Binding to Melanin

Ropinirole binds to melanin-containing tissues (i.e., eyes, skin) in pigmented rats. After a single dose, long-term retention of drug was demonstrated, with a half-life in the eye of 20 days.

6 Adverse Reactions

The following adverse reactions are described in more detail in other sections of the label:

• •Hypersensitivity [see Contraindications (4)]
• •Falling Asleep during Activities of Daily Living and Somnolence [see Warnings and Precautions (5.1)]
• •Syncope [see Warnings and Precautions (5.2)]
• •Hypotension/Orthostatic Hypotension [see Warnings and Precautions (5.3)]
• •Elevation of Blood Pressure and Changes in Heart Rate [see Warnings and Precautions (5.4) ]
• •Hallucinations/Psychotic-like Behavior [see Warnings and Precautions (5.5)]
• •Dyskinesia [see Warnings and Precautions (5.6)]
• •Impulse Control/Compulsive Behaviors [see Warnings and Precautions (5.7)]
• •Withdrawal-emergent Hyperpyrexia and Confusion [see Warnings and Precautions (5.8)]
• •Melanoma [see Warnings and Precautions (5.9)]
• •Fibrotic Complications [see Warnings and Precautions (5.10)]

• •Most common adverse reactions (incidence for ropinirole extended-release at least 5% greater than placebo) in advanced Parkinson’s disease with concomitant L-dopa were dyskinesia, nausea, dizziness, and hallucination (6.1)
• •Most common adverse reactions (incidence for ropinirole extended-release at least 5%) in early Parkinson’s disease without L-dopa were nausea, somnolence, abdominal pain/discomfort, dizziness, headache and constipation. (6.1)

To report SUSPECTED ADVERSE REACTIONS, contact Mylan Pharmaceuticals Inc. at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch.

6.1 Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug (or of another development program of a different formulation of the same drug) and may not reflect the rates observed in practice.

During the premarketing development of ropinirole extended-release, patients with advanced Parkinson’s disease received ropinirole extended-release or placebo as adjunctive therapy in one clinical trial. In a second trial, patients with early Parkinson’s disease were treated with ropinirole extended-release or the immediate-release formulation of ropinirole without L-dopa.

In the 24-week, double-blind, placebo-controlled trial for the treatment of advanced Parkinson’s disease, the most commonly observed adverse reactions in patients treated with ropinirole extended-release (incidence at least 5% greater than placebo) were dyskinesia, nausea, dizziness, and hallucination.

Approximately 6% of patients treated with ropinirole extended-release discontinued treatment due to adverse reactions compared with 5% of patients who received placebo. The most common adverse reaction in patients treated with ropinirole extended-release causing discontinuation of treatment with ropinirole extended-release was hallucination (2%).

Table 2 uls treatment-emergent adverse reactions that occurred in at least 2% (and were numerically greater than placebo) of patients with advanced Parkinson’s disease treated with ropinirole extended-release who participated in the 26-week, double-blind, placebo-controlled trial. In this trial, either ropinirole extended-release or placebo was used as an adjunct to L-dopa.

Table 2: Treatment-emergent Adverse Reaction Incidence in a Double-Blind, Placebo- Controlled Trial in Advanced Stage Parkinson’s Disease (With L-dopa) (Events ≥ 2% of Patients Treated With Ropinirole Extended-Release and > % With Placebo)Patients may have reported multiple adverse reactions during the trial or at discontinuation; thus, patients may be included in more than one category.

Body System/Adverse Reaction	Ropinirole Extended-release (n = 202) %	Placebo (n = 191) %
Ear and labyrinth disorders
Vertigo	4	2
Gastrointestinal disorders
Nausea	11	4
Constipation	4	2
Abdominal pain/discomfort	6	3
Diarrhea	3	2
Dry mouth	2	< 1
General disorders
Edema peripheral	4	1
Injury, poisoning and procedural complication
FallDose-related	2	1
Musculoskeletal and connective tissue disorders
Back pain	3	2
Nervous system disorders
Dyskinesia	13	3
Dizziness	8	3
Somnolence	7	4
Psychiatric disorders
Hallucination	8	2
Anxiety	2	1
Vascular disorders
Orthostatic hypotension	5	1
Hypotension	2	0
Hypertension	3	2

Although this trial was not designed for optimally characterizing dose-related adverse reactions, there was a suggestion (based upon comparison of incidence of adverse reactions across dose ranges for ropinirole extended-release and placebo) that the incidence for dyskinesia, hypertension, and fall was dose-related to ropinirole extended-release.

The incidence for many adverse reactions with ropinirole extended-release was increased relative to placebo (i.e., the incidence in the group receiving ropinirole extended-release was 2% or greater than placebo) in either the titration or maintenance phases of the trial. During the titration phase, an increased incidence (shown in descending order of % treatment difference) was observed for dyskinesia, nausea, abdominal pain/discomfort, orthostatic hypotension, dizziness, vertigo, hypertension, peripheral edema, and dry mouth. During the maintenance phase, an increased incidence was observed for dyskinesia, nausea, dizziness, hallucination, somnolence, fall, hypertension, abnormal dreams, constipation, chest pain, bronchitis, and nasopharyngitis. Some adverse reactions developing in the titration phase persisted (≥ 7 days) into the maintenance phase. These “persistent” adverse reactions included dyskinesia, hallucination, orthostatic hypotension, and dry mouth.

The incidence of adverse reactions was not clearly different between women and men.

In the 36-week early Parkinson’s disease trial, the most commonly observed adverse reactions in patients treated with ropinirole extended-release (≥ 5%) were nausea (19%), somnolence (11%), abdominal pain/discomfort (7%), dizziness (6%), headache (6%), and constipation (5%). The type of adverse reactions and the frequency (i.e., incidence) with which they occurred were generally similar over the whole treatment period in this trial of early Parkinson's disease patients who were initially treated with ropinirole extended-release or the immediate-release formulation of ropinirole and subsequently crossed over to treatment with the other formulation.

During the titration phase, an increased incidence with ropinirole extended-release compared with the immediate-release formulation of ropinirole (i.e., the incidence in ropinirole extended-release was 2% or greater than immediate-release ropinirole), shown in descending order of % treatment difference, was observed for constipation, hallucination, vertigo, abdominal pain/discomfort, nausea, vomiting, fall, headache, diarrhea, pyrexia, and flatulence. During the maintenance phase, an increased incidence was observed for fall, myalgia, and sleep disorder. Several adverse reactions developing in the titration phase persisted (≥ 7 days) into the maintenance phase. These “persistent” adverse reactions included constipation, hallucination, muscle spasms, flatulence, insomnia, sleep disorder, abdominal pain/discomfort, cough, and nasopharyngitis.

6.2Adverse Reactions Observed during the Clinical Development of the Immediate-release Formulation of Ropinirole for Parkinsons Disease (Advanced and Early)

Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug (or of another development program of a different formulation of the same drug) and may not reflect the rates observed in practice.

In patients with advanced Parkinson's disease who were treated with the immediate-release formulation of ropinirole, the most common adverse reactions (≥ 5% treatment difference from placebo; presented in order of decreasing treatment difference frequency) were dyskinesia (21%), somnolence (12%), nausea (12%), dizziness (10%), confusion (7%), hallucinations (6%), headache (5%), and increased sweating (5%). In patients with early Parkinson's disease who were treated with the immediate-release formulation of ropinirole, the most common adverse reactions (≥ 5% treatment difference from placebo; presented in order of decreasing treatment difference frequency) were nausea (38%), somnolence (34%), dizziness (18%), syncope (11%), asthenic condition (11%), viral infection (8%), leg edema (6%), vomiting (5%), and dyspepsia (5%).

7 Drug Interactions

• •Inhibitors or inducers of CYP1A2: May alter the clearance of ropinirole; dose adjustment may be required (7.1, 12.3)
• •Hormone replacement therapy (HRT): Starting or stopping HRT treatment may require dose adjustment of ropinirole extended-release. (7.2, 12.3)
• •Dopamine antagonists (e.g., neuroleptics, metoclopramide): May reduce efficacy of ropinirole extended-release (7.3)

7.1 CYP1A2 Inhibitors and Inducers

In vitro metabolism studies showed that CYP1A2 is the major enzyme responsible for the metabolism of ropinirole. There is thus the potential for inducers or inhibitors of this enzyme to alter the clearance of ropinirole. Therefore, if therapy with a drug known to be a potent inducer or inhibitor of CYP1A2 is stopped or started during treatment with ropinirole extended-release, adjustment of the dose of ropinirole extended-release may be required. Coadministration of ciprofloxacin, an inhibitor of CYP1A2, with immediate-release ropinirole increases the AUC and C_max of ropinirole [see Clinical Pharmacology (12.3)]. Cigarette smoking is expected to increase the clearance of ropinirole since CYP1A2 is known to be induced by smoking [see Clinical Pharmacology (12.3)].

7.2 Estrogens

Population pharmacokinetic analysis revealed that higher doses of estrogens (usually associated with hormone replacement therapy [HRT]) reduced the clearance of ropinirole. Starting or stopping HRT may require adjustment of dosage of ropinirole extended-release [see Clinical Pharmacology (12.3)].

7.3 Dopamine Antagonists

Because ropinirole is a dopamine agonist, it is possible that dopamine antagonists such as neuroleptics (e.g., phenothiazines, butyrophenones, thioxanthenes) or metoclopramide may reduce the efficacy of ropinirole extended-release.

8 Use In Specific Populations

Pregnancy: Based on animal data, may cause fetal harm (8.1)

8.1 Pregnancy

There are no adequate and well-controlled studies in pregnant women. In animal reproduction studies, ropinirole has been shown to have adverse effects on embryo-fetal development, including teratogenic effects. Ropinirole-extended-release should be used during pregnancy only if the potential benefit outweighs the potential risk to the fetus.

Oral treatment of pregnant rats with ropinirole during organogenesis resulted in decreased fetal body weight, increased fetal death, and digital malformations at 24, 36, and 60 times, respectively, the maximum recommended human dose (MRHD) for Parkinson’s disease (24 mg/day) on a mg/m² basis. The combined oral administration of ropinirole at 8 times the MRHD and a clinically relevant dose of L-dopa to pregnant rabbits during organogenesis produced a greater incidence and severity of fetal malformations (primarily digit defects) than were seen in the offspring of rabbits treated with L-dopa alone. No effect on fetal development was observed in rabbits when ropinirole was administered alone at an oral dose 16 times the MRHD on a mg/m² basis. In a perinatal-postnatal study in rats, impaired growth and development of nursing offspring and altered neurological development of female offspring were observed when dams were treated with 4 times the MRHD on a mg/m² basis.

8.3 Nursing Mothers

Ropinirole inhibits prolactin secretion in humans and could potentially inhibit lactation. Ropinirole has been detected in rat milk. It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when ropinirole is administered to a nursing woman.

8.4 Pediatric Use

Safety and effectiveness in pediatric patients have not been established.

8.5 Geriatric Use

Dose adjustment is not necessary in elderly (65 years and older) patients, as the dose of ropinirole extended-release is individually titrated to clinical therapeutic response and tolerability. Pharmacokinetic trials conducted in patients demonstrated that oral clearance of ropinirole is reduced by 15% in patients older than 65 years compared with younger patients [see Clinical Pharmacology (12.3)].

In clinical trials of ropinirole extended-release for Parkinson’s disease, 387 patients were 65 years and older and 107 were 75 and older. Among patients receiving ropinirole extended-release, hallucination was more common in elderly patients (10%) compared with non-elderly patients (2%). The incidence of overall adverse reactions increased with increasing age for both patients receiving ropinirole extended-release and placebo.

8.6 Renal Impairment

No dose adjustment is necessary in patients with moderate renal impairment (creatinine clearance of 30 to 50 mL/min). For patients with end-stage renal disease on hemodialysis, a reduced maximum dose is recommended [see Dosage and Administration (2.2), Clinical Pharmacology (12.3)].

The use of ropinirole extended-release in patients with severe renal impairment (creatinine clearance less than 30 mL/min) without regular dialysis has not been studied.

8.7 Hepatic Impairment

The pharmacokinetics of ropinirole have not been studied in patients with hepatic impairment.

10 Overdosage

The symptoms of overdose with ropinirole extended-release are generally related to its dopaminergic activity. General supportive measures are recommended. Vital signs should be maintained, if necessary.

In the Parkinson's disease program, there have been patients who accidentally or intentionally took more than their prescribed dose of ropinirole. The largest overdose reported with immediate-release ropinirole in clinical trials was 435 mg taken over a 7-day period (62.1 mg/day). Of patients who received a dose greater than 24 mg/day, reported symptoms included adverse events commonly reported during dopaminergic therapy (nausea, dizziness), as well as visual hallucinations, hyperhidrosis, claustrophobia, chorea, palpitations, asthenia, and nightmares. Additional symptoms reported for doses of 24 mg or less or for overdoses of unknown amount included vomiting, increased coughing, fatigue, syncope, vasovagal syncope, dyskinesia, agitation, chest pain, orthostatic hypotension, somnolence, and confusional state.

11 Description

Ropinirole extended-release tablets contain ropinirole, a non-ergoline dopamine agonist as the hydrochloride salt. The chemical name of ropinirole hydrochloride is 4-[2-(Dipropylamino)ethyl]-2-indolinone monohydrochloride and has a molecular formula of C₁₆H₂₄ N₂O•HCl. The molecular weight is 296.84 (260.38 as the free base).

The structural formula is:

Ropinirole hydrochloride, USP is a white to cream colored crystalline powder with a melting range of 243° to 250°C and a solubility of 133 mg/mL in water.

Each ropinirole extended-release tablet contains 2.28 mg, 4.56 mg, 6.84 mg, 9.12 mg or 13.68 mg of ropinirole hydrochloride equivalent to 2 mg, 4 mg, 6 mg, 8 mg or 12 mg of ropinirole, respectively. Inactive ingredients consist of: anhydrous lactose, black iron oxide, colloidal silicon dioxide, ethylcellulose, FD&C Red No. 40 Aluminum Lake, FD&C Yellow No. 6 Aluminum Lake, hypromellose, magnesium stearate, microcrystalline cellulose and propylene glycol. The 4 mg, 6 mg, 8 mg and 12 mg tablets also contain FD&C Blue No. 2 Aluminum Lake. In addition, the 12 mg tablets contain D&C Yellow No. 10 Aluminum Lake.

12 Clinical Pharmacology

12.1 Mechanism of Action

Ropinirole is a non-ergoline dopamine agonist. The precise mechanism of action of ropinirole as a treatment for Parkinson’s disease is unknown, although it is thought to be related to its ability to stimulate dopamine D2 receptors within the caudate-putamen in the brain.

12.2 Pharmacodynamics

Clinical experience with dopamine agonists, including ropinirole, suggests an association with impaired ability to regulate blood pressure with resulting orthostatic hypotension, especially during dose escalation. In some subjects in clinical trials, blood pressure changes were associated with the emergence of orthostatic symptoms, bradycardia, and, in one case in a healthy volunteer, transient sinus arrest with syncope [see Warnings and Precautions (5.2, 5.3)].

The mechanism of orthostatic hypotension induced by ropinirole is presumed to be due to a D₂-mediated blunting of the noradrenergic response to standing and subsequent decrease in peripheral vascular resistance. Nausea is a common concomitant symptom of orthostatic signs and symptoms.

At oral doses as low as 0.2 mg, ropinirole suppressed serum prolactin concentrations in healthy male volunteers.

Immediate-release ropinirole had no dose-related effect on ECG wave form and rhythm in young, healthy, male volunteers in the range of 0.01 mg to 2.5 mg.

Immediate-release ropinirole had no dose- or exposure related effect on mean QT intervals in healthy male and female volunteers titrated to doses up to 4 mg/day. The effect of ropinirole on QTc intervals at higher exposures achieved either due to drug interactions, hepatic impairment, or at higher doses has not been systematically evaluated.

12.3 Pharmacokinetics

Increase in systemic exposure of ropinirole following oral administration of 2 mg to 12 mg of ropinirole extended-release was approximately dose-proportional. For ropinirole extended-release, steady-state concentrations of ropinirole are expected to be achieved within 4 days of dosing.

In clinical trials with immediate-release ropinirole, more than 88% of a radiolabeled dose was recovered in urine, and the absolute bioavailability was 45% to 55%, indicating approximately 50% first-pass effect.

Relative bioavailability of ropinirole extended-release tablets compared with immediate-release tablets was approximately 100%. In a repeat-dose trial in subjects with Parkinson’s disease using ropinirole extended-release 8 mg, the dose-normalized AUC_(0-24) and C_min for ropinirole extended-release and immediate-release ropinirole were similar. Dose-normalized C_max was, on average, 12% lower for ropinirole extended-release than for the immediate-release formulation and the median time-to-peak concentration was 6 to 10 hours. In a single-dose trial, administration of ropinirole extended-release to healthy volunteers with food (i.e., high-fat meal) increased AUC by approximately 30% and C_max by approximately 44%, compared with dosing under fasted conditions. In a repeat-dose trial in patients with Parkinson’s disease, food (i.e., high-fat meal) increased AUC by approximately 20% and C_max by approximately 44%; T_max was prolonged by 3 hours (median prolongation) compared with dosing under fasted conditions [see Dosage and Administration (2)].

Ropinirole is widely distributed throughout the body, with an apparent volume of distribution of 7.5 L/kg. It is up to 40% bound to plasma proteins and has a blood-to-plasma ratio of 1:1.

Ropinirole is extensively metabolized by the liver. The major metabolic pathways are N-despropylation and hydroxylation to form the inactive N-despropyl metabolite and hydroxy metabolites. The N-despropyl metabolite is converted to carbamyl glucuronide, carboxylic acid, and N-despropyl hydroxy metabolites. The hydroxy metabolite of ropinirole is rapidly glucuronidated.

In vitro studies indicate that the major cytochrome P450 enzyme involved in the metabolism of ropinirole is CYP1A2, an enzyme known to be induced by smoking and omeprazole, and inhibited by, for example, fluvoxamine, mexiletine, and the older fluoroquinolones such as ciprofloxacin and norfloxacin.

The clearance of ropinirole after oral administration is 47 L/hr and its elimination half-life is approximately 6 hours. Less than 10% of the administered dose is excreted as unchanged drug in urine. N-despropyl ropinirole is the predominant metabolite found in urine (40%), followed by the carboxylic acid metabolite (10%), and the glucuronide of the hydroxy metabolite (10%).

Digoxin

Coadministration of immediate-release ropinirole (2 mg 3 times daily) with digoxin (0.125 mg to 0.25 mg once daily) did not alter the steady-state pharmacokinetics of digoxin in ten patients.

Theophylline

Administration of theophylline (300 mg twice daily, a substrate of CYP1A2) did not alter the steady-state pharmacokinetics of immediate-release ropinirole (2 mg 3 times daily) in 12 patients with Parkinson’s disease. Immediate-release ropinirole (2 mg 3 times daily) did not alter the pharmacokinetics of theophylline (5 mg/kg IV) in 12 patients with Parkinson’s disease.

Ciprofloxacin

Coadministration of ciprofloxacin (500 mg twice daily), an inhibitor of CYP1A2, with immediate-release ropinirole (2 mg 3 times daily) increased ropinirole AUC by 84% on average and C_max by 60% (n = 12 patients).

Estrogens

Population pharmacokinetic analysis revealed that estrogens (mainly ethinylestradiol: intake 0.6 mg to 3 mg over 4-month to 23-year period) reduced the oral clearance of ropinirole by 36% in 16 patients.

L-dopa

Coadministration of carbidopa + L-dopa (10/100 mg twice daily) with immediate-release ropinirole (2 mg 3 times daily) had no effect on the steady-state pharmacokinetics of ropinirole (n = 28 patients). Oral administration of immediate-release ropinirole 2 mg 3 times daily increased mean steady-state C_max of L-dopa by 20%, but its AUC was unaffected (n = 23 patients).

Commonly Administered Drugs

Population analysis showed that commonly administered drugs, e.g., selegiline, amantadine, tricyclic antidepressants, benzodiazepines, ibuprofen, thiazides, antihistamines, and anticholinergics, did not affect the clearance of ropinirole. An in vitro study indicates that ropinirole is not a substrate for P-gp. Ropinirole and its circulating metabolites do not inhibit or induce P450 enzymes; therefore, ropinirole is unlikely to affect the pharmacokinetics of other drugs by a P450 mechanism.

Because therapy with ropinirole extended-release is initiated at a low dose and gradually titrated upward according to clinical tolerability to obtain the optimum therapeutic effect, adjustment of the initial dose based on gender, weight, or age is not necessary.

Age

Oral clearance of ropinirole is reduced by 15% in patients older than 65 years compared with younger patients. Dosage adjustment is not necessary in the elderly (older than 65 years), as the dose of ropinirole is to be individually titrated to clinical response.

Gender

Female and male patients showed similar clearance.

Race

The influence of race on the pharmacokinetics of ropinirole has not been evaluated.

Cigarette Smoking

Smoking is expected to increase the clearance of ropinirole since CYP1A2 is known to be induced by smoking. In a trial in patients with Restless Legs Syndrome, smokers (n = 7) had an approximately 30% lower C_max and a 38% lower AUC than did nonsmokers (n = 11) when those parameters were normalized for dose.

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 immediate-release 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 should be lower in these patients [see Dosage and Administration (2.2)].

The use of ropinirole in subjects with severe renal impairment (creatinine clearance less than 30 mL/min) without regular dialysis has not been studied.

Hepatic Impairment

The pharmacokinetics of ropinirole have not been studied in patients with hepatic impairment. Because ropinirole is extensively metabolized by the liver, these patients may have higher plasma levels and lower clearance of ropinirole than patients with normal hepatic function.

Other Diseases

Population pharmacokinetic analysis revealed no change in the clearance of ropinirole in patients with concomitant diseases such as hypertension, depression, osteoporosis/arthritis, and insomnia compared with patients with Parkinson’s disease only.

13 Nonclinical Toxicology

13.1 Carcinogenesis, Mutagenesis, Impairment of Fertility

Two-year carcinogenicity studies of ropinirole were conducted in mice at oral doses of 5, 15, and 50 mg/kg/day and in rats at oral doses of 1.5, 15, and 50 mg/kg/day.

In rats, there was an increase in testicular Leydig cell adenomas at all doses tested. The lowest dose tested (1.5 mg/kg/day) is less than the MRHD for Parkinson’s disease (24 mg/day) on a mg/m² basis. The endocrine mechanisms believed to be involved in the production of these tumors in rats are not considered relevant to humans.

In mice, there was an increase in benign uterine endometrial polyps at a dose of 50 mg/kg/day. The highest dose not associated with this finding (15 mg/kg/day) is three times the MRHD on a mg/m² basis.

Ropinirole was not mutagenic or clastogenic in in vitro (Ames, chromosomal aberration in human lymphocytes, mouse lymphoma tk) assay, or in the in vivo mouse micronucleus test.

When administered to female rats prior to and during mating and throughout pregnancy, ropinirole caused disruption of implantation at oral doses of 20 mg/kg/day (8 times the MRHD on a mg/m² basis) or greater. This effect in rats is thought to be due to the prolactin-lowering effect of ropinirole. In rat studies using a low oral dose (5 mg/kg) during the prolactin-dependent phase of early pregnancy (gestation days 0 to 8), ropinirole did not affect female fertility at oral doses up to 100 mg/kg/day (40 times the MRHD on a mg/m² basis). No effect on male fertility was observed in rats at oral doses up to 125 mg/kg/day (50 times the MRHD on a mg/m² basis).

14 Clinical Studies

The effectiveness of ropinirole was initially established with the immediate-release formulation of ropinirole (ropinirolee tablets) for the treatment of early and advanced Parkinson’s disease in three randomized, double-blind, placebo-controlled trials.

The effectiveness of ropinirole extended-release in the treatment of Parkinson’s disease was supported by two randomized, double-blind, multicenter clinical trials and clinical pharmacokinetic considerations. One trial conducted in patients with advanced Parkinson’s disease compared ropinirole extended-release with placebo as adjunctive therapy to L-dopa. A second trial compared ropinirole extended-release tablets with ropinirole tablets in patients with early phase Parkinson’s disease not receiving L-dopa.

In these trials a variety of measures were used to assess the effects of treatment (e.g., Unified Parkinson’s Disease Rating Scale [UPDRS] scores, patient diaries recording time “on” and “off”, tolerability of L-dopa dose reductions). The UPDRS is a multi-li rating scale intended to evaluate mentation (Part I), activities of daily living (Part II), motor performance (Part III), and complications of therapy (Part IV). Part III of the UPDRS contains 14 lis designed to assess the severity of the cardinal motor findings in patients with Parkinson’s disease (e.g., tremor, rigidity, bradykinesia, postural instability) scored for different body regions and has a maximum (worst) score of 108.

14.1Trial in Patients with Advanced Parkinsons Disease (with L-dopa)

The effectiveness of ropinirole extended-release as adjunctive therapy to L-dopa in patients with Parkinson’s disease was established in a randomized, double-blind, placebo-controlled, parallel group, 24-week clinical trial in 393 patients (Hoehn & Yahr criteria Stages II to IV) who were not adequately controlled by L-dopa therapy. Patients were allowed to be on concomitant selegiline, amantadine, anticholinergics, and catechol-O-methyltransferase (COMT) inhibitors provided the doses were stable for at least 4 weeks prior to screening and throughout the trial. The primary efficacy endpoint evaluated was the mean change from baseline in total awake time spent “off”.

Patients in this trial had a mean disease duration of 8.6 years, a mean duration of exposure to L-dopa of 6.5 years, had experienced a minimum of 3 hours awake time “off” with a baseline average of approximately 7 hours awake time “off”, and had a mean baseline UPDRS motor score of approximately 30 points with similar mean data in each treatment group. The mean baseline dose of L-dopa in the group receiving ropinirole extended-release was 824 mg/day and 776 mg/day for the placebo group. Patients initiated treatment at 2 mg/day for one week followed by increases of 2 mg/day at weekly intervals to a minimum dose of 6 mg/day. The following week, the total daily dose of ropinirole extended-release could be further increased (based upon therapeutic response and tolerability) to 8 mg/day. Once a daily dose of 8 mg/day was reached, the background L-dopa dosage was reduced. Thereafter, the daily dose could be increased by up to 4 mg/day approximately every 2 weeks until an optimal dose was achieved (based upon therapeutic response and tolerability). The mean dose of ropinirole extended-release at the end of Week 24 was 18.8 mg/day. Dose titrations were based upon the degree of symptom control, planned L-dopa dosage reduction, and/or tolerability. The maximum allowed daily dosage for ropinirole extended-release was 24 mg/day.

The primary efficacy endpoint was mean change from baseline in total awake time spent “off” at Week 24. At baseline the mean total awake time spent “off” was approximately 7 hours in each treatment group. At Week 24, the total awake time spent “off”, on average, had decreased by approximately 2 hours in the group receiving ropinirole extended-release and by approximately half an hour in the placebo group. The adjusted mean difference in total awake time spent “off” between ropinirole extended-release and placebo was -1.7 hours, which was statistically significant (ANCOVA, P < 0.0001). Results for this endpoint showing the statistical superiority of ropinirole extended-release over placebo are presented in Table 3.

Table 3: Change from Baseline in Total Awake Time Spent "Off" at Week 24

	Ropinirole Extended-release (n = 201)	Placebo (n = 190)
Mean “off” time at baseline (hours)	7	7
Mean change from baseline in “off” time (hours)	-2.1	-0.4

The difference between groups in favor of ropinirole extended-release, with regard to a decrease in total “off” hours, was primarily related to an increase in total “on” hours without troublesome dyskinesia. Patients treated with ropinirole extended-release had a mean reduction in L-dopa dose of 278 mg/day (34%) while patients treated with placebo had a mean reduction of 164 mg/day (21%). In patients who reduced their L-dopa dose, reduction was sustained in 93% of patients treated with ropinirole extended-release and in 72% of patients treated with placebo (P < 0.001).

14.2Trial in Patients with Early Parkinsons Disease (without L-dopa)

A 36-week multicenter, double-blind, titration/3-period maintenance, cross-over trial compared the efficacy of ropinirole extended-release with the immediate-release formulation of ropinirole in 161 patients with early phase Parkinson’s disease (Hoehn & Yahr Stages I to III) with limited prior exposure to L-dopa or dopamine agonists. Eligible patients were randomized (1:1:1:1) to four treatment sequences (two were titrated on ropinirole immediate-release and two on ropinirole extended-release). Titration rate of ropinirole tablets was slower than that of the ropinirole extended-release. Patients were titrated, during the 12-week titration period, to their optimal dosage, based upon tolerance and therapeutic response. This was followed by three consecutive 8-week maintenance periods, during which patients were either maintained on the prior formulation or switched to the alternative formulation. All switches were performed overnight by using the approximately equivalent doses of ropinirole. The primary efficacy endpoint was the change of UPDRS motor score within each maintenance period.

Patients in all four groups started out with similar UPDRS motor scores (about 21) at baseline. All groups exhibited similar improvement in UPDRS total motor scores from baseline until the completion of the titration phase, with a change in score of about -9 observed for the groups started on ropinirole immediate-release and of about -10 for the groups started on ropinirole extended-release. No difference was observed between groups when switches were made between identical formulations or between different formulations. This suggests therapeutic dosage equivalence between formulations of ropinirole immediate-release and ropinirole extended-release.

The optimal daily dose at the end of the titration period for patients on ropinirole immediate-release was substantially lower (mean 7 mg) compared with the dose at the end of the titration period for patients on ropinirole extended-release (mean 18 mg). In this trial, the marked difference in the final optimal dosages suggests that the higher doses afforded no additional benefit when compared with the lower doses [see Dosage and Administration (2.2)].

16 How Supplied/storage And Handling

Ropinirole Extended-release Tablets are available containing 2.28 mg, 4.56 mg, 6.84 mg, 9.12 mg or 13.68 mg of ropinirole hydrochloride, USP equivalent to 2 mg, 4 mg, 6 mg, 8 mg or 12 mg of ropinirole, respectively.

The 2 mg tablets are pink, clear film-coated, round, unscored tablets with M over RE2 imprinted in black ink on one side of the tablet and blank on the other side.They are available as follows:

NDC 0378-4090-93bottles of 30 tablets

The 4 mg tablets are light brown, clear film-coated, round, unscored tablets with M over RE4 imprinted in black ink on one side of the tablet and blank on the other side.They are available as follows:

NDC 0378-4091-93bottles of 30 tablets

The 6 mg tablets are off-white, clear film-coated, round, unscored tablets with M over RE6 imprinted in black ink on one side of the tablet and blank on the other side.They are available as follows:

NDC 0378-4092-93bottles of 30 tablets

The 8 mg tablets are red, clear film-coated, round, unscored tablets with M over RE8 imprinted in black ink on one side of the tablet and blank on the other side.They are available as follows:

NDC 0378-4093-93bottles of 30 tablets

The 12 mg tablets are green, clear film-coated, round, unscored tablets with M over RE12 imprinted in black ink on one side of the tablet and blank on the other side.They are available as follows:

NDC 0378-4094-93bottles of 30 tablets

Store at 20° to 25°C (68° to 77°F). [See USP Controlled Room Temperature.]

Dispense in a tight, light-resistant container as defined in the USP using a child-resistant closure.

PHARMACIST: Dispense a Patient Information Leaflet with each prescription.

17 Patient Counseling Information

Advise the patient to read the FDA-approved patient labeling (Patient Information).

Dosing Instructions: Instruct patients to take ropinirole extended-release tablets only as prescribed. If a dose is missed, advise patients not to double their next dose. Ropinirole extended-release tablets can be taken with or without food. Inform patients to swallow ropinirole extended-release tablets whole and not to chew, crush, or divide the tablets [see Dosage and Administration (2.1)].

Ropinirole is the active ingredient in both ropinirole extended-release tablets and ropinirole tablets (the immediate-release formulation). Ask your patients if they are taking another medication containing ropinirole.

Hypersensitivity/Allergic Reactions: Advise patients about the potential for developing a hypersensitivity/allergic reaction including manifestations such as urticaria, angioedema, rash, and pruritus when taking any ropinirole product. Inform patients who experience these or similar reactions after starting ropinirole tablets or ropinirole extended-release tablets, to immediately contact their healthcare professional [see Contraindications (4)].

Falling Asleep during Activities of Daily Living and Somnolence: Alert patients to the potential sedating effects caused by ropinirole extended-release, including somnolence and the possibility of falling asleep while engaged in activities of daily living. Because somnolence is a frequent adverse reaction with potentially serious consequences, patients should not drive a car, operate machinery, or engage in other potentially dangerous activities until they have gained sufficient experience with ropinirole extended-release to gauge whether or not it affects their mental and/or motor performance adversely. Advise patients that if increased somnolence or episodes of falling asleep during activities of daily living (e.g., conversations, eating, driving a motor vehicle, etc.) are experienced at any time during treatment, they should not drive or participate in potentially dangerous activities until they have contacted their physician.

Advise patients of possible additive effects when patients are taking other sedating medications, alcohol, or other central nervous system depressants (e.g., benzodiazepines, antipsychotics, antidepressants, etc.) in combination with ropinirole extended-release tablets or when taking a concomitant medication (e.g., ciprofloxacin) that increases plasma levels of ropinirole [see Warnings and Precautions (5.1)].

Syncope and Hypotension/Orthostatic Hypotension: Advise patients that they may experience syncope and may develop hypotension with or without symptoms such as dizziness, nausea, syncope, and sometimes sweating while taking ropinirole extended-release tablets, especially if they are elderly. Hypotension and/or orthostatic symptoms may occur more frequently during initial therapy or with an increase in dose at any time (cases have been seen after weeks of treatment). Postural/orthostatic symptoms may be related to sitting up or standing. Accordingly, caution patients against standing rapidly after sitting or lying down, especially if they have been doing so for prolonged periods and especially at the initiation of treatment with ropinirole extended-release tablets [see Warnings and Precautions (5.2 , 5.3)].

Elevation of Blood Pressure and Changes in Heart Rate: Alert patients to the possibility of increases in blood pressure during treatment with ropinirole extended-release. Exacerbation of hypertension may occur. Medication dose adjustment may be necessary if elevation of blood pressure is sustained over multiple evaluations. Alert patients with cardiovascular disease, who may not tolerate marked changes in heart rate, to the possibility that they may experience significant increases or decreases in heart rate during treatment with ropinirole extended-release [see Warnings and Precautions (5.4)].

Hallucinations/Psychotic-like Behavior: Inform patients that they may experience hallucinations (unreal visions, sounds, or sensations) and other psychotic-like behavior can occur while taking ropinirole-extended-release tablets. The elderly are at greater risk than younger patients with Parkinson's disease. This risk is greater in patients who are taking ropinirole extended-release tablets with L-dopa or taking higher doses of ropinirole extended-release tablets and may also be further increased in patients taking any other drugs that increase dopaminergic tone. Tell patients to report hallucinations or psychotic-like behavior to their healthcare provider promptly should they develop [see Warnings and Precautions (5.5)].

Dyskinesia: Inform patients that ropinirole extended-release tablets may cause and/or exacerbate pre-existing dyskinesias [see Warnings and Precautions (5.6)].

Impulse Control/Compulsive Behaviors: Advise patients that they may experience impulse control and/or compulsive behaviors while taking one or more of the medications (including ropinirole extended-release tablets) that increase central dopaminergic tone, that are generally used for the treatment of Parkinson’s disease. Advise patients to inform their physician or healthcare provider if they develop new or increased gambling urges, sexual urges, uncontrolled spending, binge or compulsive eating, or other urges while being treated with ropinirole extended-release tablets. Physicians should consider dose reduction or stopping the medication if a patient develops such urges while taking ropinirole extended-release tablets [see Warnings and Precautions (5.7)].

Withdrawal-emergent Hyperpyrexia and Confusion: Advise patients to contact their healthcare provider if they wish to discontinue ropinirole extended-release tablets or decrease the dose of ropinirole extended-release tablets [see Warnings and Precautions (5.8)].

Melanoma: Advise patients with Parkinson’s disease that they have a higher risk of developing melanoma. Advise patients to have their skin examined on a regular basis by a qualified healthcare provider (e.g., dermatologist) when using ropinirole extended-release tablets [see Warnings and Precautions (5.9)].

Nursing Mothers: Because of the possibility that ropinirole may be excreted in breast milk, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother [see Use in Specific Populations (8.3)]. Advise patients that ropinirole extended-release tablets could inhibit lactation, because ropinirole inhibits prolactin secretion.

Pregnancy: Because ropinirole has been shown to have adverse effects on embryo-fetal development, including teratogenic effects, in animals, and because experience in humans is limited, advise patients to notify their physician if they become pregnant or intend to become pregnant during therapy [see Use in Specific Populations (8.1)].