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Gabapentinoid Questions

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Dr. Salsitz's presentation and discussion about gabapentinoids was very helpful today.  I have a couple questions:

1.  Striving to keep patients at or under 1800mg/day of gabapentin is a useful guideline.  Is there any benefit in QID vs TID dosing?

2. To assist with appropriate monitoring of patients, do you recommend pill counts?  Is a quantitative urine level useful (therapeutic vs toxic levels) or is it just to confirm they are taking it?

Thank you!

 

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Along with that presentation, I also have a question regarding pregabalin and gabapentin use:

I was hoping to get your opinion on the use of pregabalin for neuropathic pain for patients with a history of suicidal ideation.   I know some studies and case reports associate gabapentinoids and suicidal ideation, and the warning is still listed in the Pregabalin package insert based off a pooled analysis of a few different anti-epileptics, but I wanted to see how you would consider using pregabalin for someone with a past medical history of suicidal ideation (commonly seen in patients with chronic pain issues).

 

Thank you.

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Thank you Dr. Salsitz for the gabapentin talk today. I was hoping to hear more information about the use of gabapentin in alcohol withdrawal to limit seizures.

I can't find much research for or against it for this use. Our MH prescribers prescribe gabapentin as an alternative to benzodiazepines when treating alcohol w/d in the outpatient setting and to limit alcohol craving/anxiety/insomnia, but also to prevent seizures.  I would like to enquire about the effectiveness/ineffectiveness of this med class to limit alcohol w/d seizures?

Thank you!

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#1. Dosing of gabapentanoids should be tid or qid. Half life ~ 6 hours. There are now 2 long acting gabapentins and a long acting pregabalin formulations. These are more expensive and would probably require a prior authorization.

Concerns over misuse of gabapentanoids should be managed in a similar paradigm as misuse of other medications. Urine testing would require sending to lab as I don't know of a point of care immunoassay for gabapentanoids.

#2. I don't have any informed advice on the suicide issue as it relates to gabapentanoids. 

#3. I presented a study comparing lorazepam to gabapentin in an outpatient alcohol withdrawal study(attached). I do not believe there have been publications specifically addressing  prevention of seizures in the alcohol withdrawal syndrome. Benzodiazepines remain the first line drug class in treating alcohol withdrawal.

Alcohol_Withdrawal_Acute_Myrick.pdf

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