With the opioid crisis, the prescription of gabapentin and pregabalin (also known as "gabapentinoids") has surged as alternatives to opioids. A study (figure below) shows the rise in prescription, particularly among patients who used other medications for chronic pain.
But are gabapentinoids truly effective, and what about their side effects?
Efficacy and side effects
Gabapentinoids have shown efficacy in treating certain types of neuropathic pain and fibromyalgia. However, a high proportion of patients with neuropathic pain do not benefit (see here), and many studies have found no significant benefit compared to placebo in other pain conditions. Even when gabapentinoids reduce pain, the side effects may outweigh their potential pain-relieving effects. Sedation and cognitive impairment are frequent, and may have consequences.
New information: risk of hip fractures
A recent study linked the use of gabapentinoids to an increased risk of hip fractures, likely due to an increased risk of falls. Taking additional medications for pain that also cause sedation and cognitive impairment, being older, and having osteoporosis are all factors that increase the risk of falls and fractures. (You can read more about pain management in osteoporotic fractures here).
Use in low back pain and radicular pain
Gabapentinoids are frequently prescribed for low back pain and radicular (“sciatica”) pain. However, systematic reviews have found them to be ineffective for these conditions and associated with an increased risk of adverse events:
Enke et al. (2018): Found anticonvulsants ineffective for low back pain and lumbar radicular pain, and associated with adverse events.
Shanthanna et al. (2017): Obtained similar findings regarding chronic low back pain.
Giménez-Campos et al. (2022): Highlighted the ineffectiveness and adverse events of gabapentin and pregabalin for radicular (sciatica) pain.
Postoperative pain management
Gabapentinoids are also prescribed for postoperative pain management, often as supplements to opioids. However, their effectiveness in this context is unclear:
Verret et al. (2020): Found gabapentinoids ineffective for postoperative pain and prevention of chronic pain after surgery, with an increased risk of adverse events.
Tsai et al. (2023): Reported that gabapentinoids were better than placebo for postoperative pain after spine surgery.
Are gabapentinoids overprescribed?
Likely, yes. In many cases, their use is prompted by limited alternatives to opioids, but the question is whether the benefits outweigh the risks.
Gabapentinoids may or may not offer pain relief, depending on the pain condition and the individual patient. But they are likely to increase the risk of adverse effects. These drugs affect the central nervous system, frequently causing sedation and cognitive impairment, which can impair patients' ability to function and increase the risk of falls, particularly in elderly and frail individuals. If prescribed, it is essential to regularly evaluate their effectiveness and consider tapering off if they are not providing the desired benefits.
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