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14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

Medication Selection for Comorbid Pain Management (Part 3)

In Part 3 of this series, this case examines treatment options for managing a patient with diabetic peripheral neuropathy, kidney disease, and a substance use disorder.
Pages 34-36
Page 2 of 2

Gabapentinoids, which include gabapentin and pregabalin, work by blocking the alpha-2-delta subunit of the voltage-gated calcium channel, leading to reduced levels of excitatory neurotransmitters.13,18 Gabapentin is FDA-indicated for post-herpetic neuralgia (PHN) and adjunctive treatment for partial onset seizures, but is often used off-label for treating neuropathic pain.18 Pregabalin has several pain-related indications including diabetic peripheral neuropathy, PHN, fibromyalgia, and neuropathic pain associated with spinal cord injury as well as adjunctive treatment of partial onset seizures in adults.19 Other uses of gabapentinoids may include restless legs syndrome, anxiety, and insomnia.13 Recent guidelines from the American Psychiatric Association for the pharmacological treatment of alcohol use disorder suggest the use of topiramate or gabapentin. (These medications may be offered to those who failed or have contraindications to naltrexone and acamprosate or prefer topiramate or gabapentin.) Therefore, gabapentin may be used to target the case patient’s neuropathic pain while also potentially helping to reduce his use of alcohol.20 (See more guidelines for neuropathic pain in Table I.)

Typically, gabapentin is initiated at 100 to 300 mg by mouth at bedtime or 100 to 300 mg three times daily. The dose may then be titrated in 100 to 300 mg/day increments every 3 to 7 days until effect, as tolerated, up to a maximum dose of 3600 mg/day.13 Importantly, gabapentin (and pregabalin) require renal dose adjustments beginning at CrCl < 60 mL/min.18 For Mr. Stevens, with a CrCl = 43mL/min, the recommended maximum dose would be 1,400 mg/day in two divided doses. The total daily dose should not only be reduced but the frequency of dosing should also change. Slow dosage titration will be essential to lessen adverse effects. Common side effects may include dizziness and sedation. Another typical adverse effect is peripheral edema.13,18 Infrequently, although with increasing reports, gabapentinoids have been associated with misuse and abuse (Note: PPM is polling its readers about this online; look for feedback reports in early 2019). Patients with a history of substance use disorder, particularly opioid use disorder, may be at higher risk for gabapentinoid abuse. Thus, it is important to monitor the patient’s adherence and look for signs of misuse and abuse.21 (Note: See also Part 1 in this case series for a table listing which medical conditions may benefit from TCAs, SNRIs, and gabapentinoids.1)

Conclusion

Patient-specific factors, including comorbidities, are important considerations when selecting non-opioid medications. These may help clinicians decide to use a medication to treat more than diagnosis concurrently. Also, a comorbidity may steer prescribers away from using a specific medication. In this particular case, the elderly patient presenting with painful diabetic peripheral neuropathy, BPH, and a likely alcohol use disorder may do best to discontinue any TCA usage that is worsening his BPH and leading to confusion and try a slow-dose titration of gabapentin to help manage his pain and possibly reduce his alcohol use.

Last updated on: December 3, 2018
Continue Reading:
Medication Selection for Comorbid Pain Management (Part 2)
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