Why is gabapentin titration

Neuropathic pain is a chronic debilitating pain syndrome that is complex to treat. Current medication management for neuropathic pain includes select neuromodulating agents such as anticonvulsants, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants, and certain opioids.

For patients on dialysis, gabapentin can often be 3 times weekly following dialysis. Several cross-sectional studies have reported gabapentin being used in subtherapeutic doses among most patients. The cornerstones of effective pharmacotherapy are the right patient, the right drug, and the right dose. If an analgesic medication is being used at a suboptimal dose, oftentimes a knee-jerk reaction is to add another analgesic for synergy.

While this may well be indicated under appropriate circumstances, it is inappropriate without maximizing the dose of each single agent with careful attention to dose titration in order to minimize toxicity of each add-on.

This adds to polypharmacy, increased costs, and the pain remains inadequately treated. Pharmacists as medication experts can collaborate with prescribers to optimize the rational use of gabapentin in neuropathic pain.

Receptor binding causes presynaptic inhibition of excitatory neurotransmitter release i. Gabapentin has saturable, non-linear absorption kinetics, where bioavailability decreases as the dose increases. Pregabalin boasts a binding affinity for the alphadelta receptor that is six times greater than that of gabapentin. Patients should be aware of the therapeutic dosing for neuropathic pain to establish realistic expectations and improve compliance and likelihood of remaining on therapy.

If dose increases along the titration cause intolerable side effects such as dizziness or drowsiness, this can often be overcome by reducing back to the previous dose and escalating more slowly over a longer period of time.

Another mishap with gabapentin that contributes to treatment failure is when patients take it on an as needed basis. Gabapentin exhibits its activity by impeding calcium trafficking and is required to be present at the alphadelta receptor for hours in order to ensure efficacy.

This is another area that pharmacists can educate patients at initiation of therapy to improve compliance. Despite its therapeutic role in neuropathic pain, gabapentin produces psychoactive effects and has an abuse liability.

Gabapentin abuse typically involves taking higher doses in a single administration. The median single dose for gabapentin abuse is mg, which is 3 times the maximum recommended single dose of mg. Alcohol use disorder is not generally a predictor of gabapentin abuse.

In conclusion, pharmacists as medication experts are well-poised to educate prescribers and patients on therapeutic dosing of gabapentin to optimize its rational and appropriate use for treating neuropathic pain. This commentary was collaboratively written with Shannon Donovan and Dr.

Mena Raouf. This article is the sole work of the authors, and the stated opinions or assertions do not reflect the opinions of employers, employee affiliates, or any pharmaceutical companies listed.

Treatment of neuropathic pain: an overview of recent guidelines. Am J Med ; Suppl :S22— Background: Gabapentin is a safe and well-tolerated anticonvulsant with a wide therapeutic index, and it is used for neuropathic pain. The aim of this study was to compare previous dosing methods with the administration of four different doses of gabapentin while maintaining the same maximum daily dose for the safe administration of high doses of the medication.

The TID group received equal doses of gabapentin 3 times per day, while the QID group received 4 different doses of gabapentin per day. The pain score, frequency of breakthrough pain BTP , severity and the duration of pain, sleep disturbance due to nocturnal pain, and adverse effects were recorded each day.

Results: The average daily pain score and sleep disturbance were significantly reduced in the QID group between days 3 and 10 of the experiment.