Deprescribing gabapentinoids

Deprescribing gabapentinoids

• Guidance on deprescribing gabapentin and pregabalin is more limited than for other medicines such as opioids or benzodiazepines, but many of the same general principles apply
• Provide the patient with information about deprescribing and the dose tapering process, including possible benefits (e.g. less weight gain, oedema, sedation, improved cognition, concentration and memory problems, sexual function) and potential withdrawal symptoms (e.g. insomnia, headache, sweating) and when to seek help
• Ensure the patient has adequate support at home (otherwise assistance from a specialist service may be needed)
• Increase the dispensing frequency as appropriate, e.g. to weekly, set days of the week or daily. N.B. This approach will not be appropriate for all patients, e.g. if a pharmacy is not easily accessible.
• Consider the length of time the medicine has been taken for, the dose and physiological factors, e.g. age, weight, when deciding on a tapering regimen. Starting with a small reduction that is likely to be well tolerated can build confidence and trust.
• A suggested tapering regimen is:
  • 5 – 10% of the current total dose, every two to six weeks (re-calculate dose at each step)
  • Response to dose reduction will vary considerably between patients, depending on their starting dose and duration of use, but in general a dose reduction step should usually not exceed:
    • 50 – 100 mg pregabalin in one week
    • 300 mg gabapentin in one week
  • Some patients may tolerate a quicker taper (e.g. up to 25% dose reduction at each step), or some may need a longer and slower taper
• As the total dose reduces, keep the percentage dose reduction the same rather than the amount you are reducing the dose by, e.g. at 3,600 mg gabapentin daily, a 10% reduction is 360 mg, while at 1,200 mg daily, a 10% reduction is 120 mg (i.e. you would not reduce the latter dose by 360 mg)
• Monitor the patient regularly throughout the dose tapering process (either in person or via phone, text/email or patient portal)
• Adjust dose reduction according to patient tolerability (suggest the patient keeps a diary of withdrawal symptoms). Hold the dose where necessary. Avoid increasing the dose where possible, but there may be some patients for whom returning to the previous dose is temporarily required.
  • Consider discussion with, or referral to, a pain or addiction medicine specialist for patients experiencing significant withdrawal symptoms or who have difficulty withdrawing completely
• There is currently no evidence to support adjunctive treatments (e.g. benzodiazepines) when tapering gabapentinoids
• Withdrawal symptoms once gabapentinoids have been discontinued may also occur, usually within 48 hours after stopping. The most frequently reported symptoms include anxiety, insomnia, nausea, sweating, dizziness, headache, tremor, low mood and a feeling of malaise.