B-QuiCK: Gabapentinoids

Gabapentinoids

Before prescribing

• Consider other treatments for neuropathic pain, including non-pharmacological strategies (e.g. exercise, physiotherapy, behavioural and cognitive interventions), and other pharmacological treatments (e.g. TCAs [unapproved indication])
• Perform a risk benefit analysis
  • Is there evidence gabapentinoids are effective for managing the patient’s specific type of neuropathic pain?
  • Check for concomitant medicines that may interact, e.g. CNS depressants
  • Assess the risk of misuse, dependence or diversion
  • Discuss potential adverse effects
• Set measurable and realistic outcomes to assess treatment response, e.g. a reduction in pain score, or the ability to perform a task or participate in an activity they could not do before

Prescribing gabapentinoids

• Select gabapentin or pregabalin. Both medicines are equally effective but individual response is variable.
  • Lower doses of pregabalin are taken to achieve efficacy equivalent to gabapentin
  • Titration of pregabalin may be faster than gabapentin
  • Pregabalin is associated with a higher risk of misuse
• Start low and titrate dose to achieve maximum benefit or to reach the maximum tolerated dose. Use lower doses of gabapentin and pregabalin in people with frailty or renal impairment.
• Allow an adequate trial period of at least four weeks or after at least two weeks at the maximum tolerated dose
• Assess treatment response
• Monitor for adverse effects and manage as required
• Assess the goals of treatment regularly and review the continued need for medicines; after pain is stable, attempt a gradual dose reduction

Switching or stopping medicines

• Consider switching to or adding another neuropathic pain medicine if initial response is inadequate
• Based on patient tolerability to the original medicine and clinical judgement, a stop/start, cross taper or taper down and up-titration method can be used to switch between gabapentinoids
• A gradual dose taper is required when stopping a gabapentinoid completely
• Reconsider the diagnosis of neuropathic pain or consider whether an underlying condition is worsening if patients have trialled multiple first-line medicines without benefit