EM Quick Hits Video on Gabapentinoids with Hans Rosenberg

When to use gabapentinoids such as gabapentin or lyrica for pain control in the ED

Back in Episode 126 Drugs that Work and Drugs That Don’t – Part 1: Analgesics the bottom line for use of gabapentinoids in the ED:

  • They are not recommended for routine use in patients with low back pain
  • They should be reserved for patients with post-herpetic neuralgic and diabetic nephropathy; they should be used at the lowest dose and stopped on day 3 if there is no effect.
  • There is an associated risk of suicidal behaviour, unintentional injuries, traumatic injuries, and road traffic incidents and offences (pregabalin > gabapentin.)

Mechanism of action: not directly on GABA. Instead, they inhibit calcium influx into glutaminergic neurons in the CNS modulating pain.

The 2 most commonly used gabapentinoids are gabapentin and pregabalin

  • Gabapentin has a lower bioavailability, less predictable pharmacokinetics and requires a longer titration duration to reach an effective dose.
    • Effective dose reached in ~ 14 days.
  • Pregabalin
    • Effective dose reached in ~ 7 days.

The long titration period of these medications means they are unlikely to be effective for pain control in the ED.

When to consider prescribing gabapentinoids:

  1. Post-herpetic neuralgia
  2. Diabetic nephropathy
  3. Only in patients who have reliable follow-up for titration and/or discontinuation

Side effects and risks of gabapentinoids include dizziness, somnolence, gait disturbances, GI upset, peripheral edema, and blurred vision. The most serious side effect is respiratory depression, especially if using concurrent opioids or sedatives. They increase the risk of opioid-related death. They should be avoided in patients with CHF (increased peripheral edema and weight gain) and renal impairment (renal excretion).

Bottom line => Exercise caution when prescribing gabapentinoids in the ED. Consider only for patients with post-herpetic neuralgia and diabetic neuropathy. All patients need a good follow-up plan for titration and discontinuation.

The Podcast: EM Quick Hits 55 – Induction Agents, Gabapentinoids for Pain Control, Neuroprotective Intubation, Approach to Paresthesias

Podcast and Written Summary

In each EM Quick Hits Video, our team hand picks an EM Quick Hits podcast segment and curates a video to enhance you multimodal learning.

Our EM Quick Hits Video team is: Lara Murphy, Yajur Iyengar and Jonathan Whittall