Gabapentin is the 10th most prescribed drug in the United States and use is increasing.  In 2002, 1% of adults were taking gabapentinoids (gabapentin and or pregabalin).  By 2015 that number increased to 4% of US adults.

There are a lot of reasons that may explain the massive increase in use of these drugs.  One thing is clear, it is not because people are using it for FDA approved indications.  The FDA-approved indications for gabapentin are only for treating patients with partial seizures or postherpetic neuralgia. However, most gabapentin prescriptions are written off-label indications.

On today's podcast we talk all about the Gabapentinoids - Gabapentin and Pregabalin - with Tasce Bongiovanni, Donovan Maust and Nisha Iyer.   It’s a big episode covering a lot of topics.

First, Nisha, a pain and palliative care pharmacist, starts us off with discussing the pharmacology of gabapentin and pregabalin, including common myths like they work on the GABA system (which is weird given the name of the drug).  

Tasce, a surgeon and researcher, reviews the use of gabapentin in the perioperative setting and the research she had done on the prolonged use of newly prescribed gabapentin after surgery (More than one-fifth of older adults prescribed gabapentin postoperatively continue to take it more than 3 months later). 

Donovan discusses the growth of “mood stabilizers/antiepileptics” (e.g. valproic acid and gabapentin), in nursing homes, particularly patients with Alzheimer's disease and related dementias. This includes a JAGS study recently published in 2022 showing that we seem to be substituting one bad drug (antipsychotics and opioids) with another bad drug (valproic acid and gabapentin).

Lastly, we also addressed a big reason for the massive uptake of gabapentinoids: an intentional and illegal strategy by the makers of these drugs to promote off-label use by doing things like creating low-quality, industry-funded studies designed to exaggerate the perceived analgesic effects of these drug.  This long and sordid history of gabapentin and pregabalin is beautifully described in Seth Landefeld and Mike Steinman 2009 NEJM editorial.

I could go on and on, but listen to the podcast instead and for a deeper dive, take a look at the following articles and studies:

• Gabapentin in the Perioperative setting:

• Prolonged use of newly prescribed gabapentin after surgery. J Am Geriatr Soc. 2022

• Perioperative Gabapentin Use in Older AdultsRevisiting Multimodal Pain Management JAMA IM. 2022

• Effect of Perioperative Gabapentin on Postoperative Pain Resolution and Opioid Cessation in a Mixed Surgical Cohort.  JAMA Surgery 2018

• Gabapentin and mood stabilizers in the Nursing Home Setting:

• Antiepileptic prescribing to persons living with dementia residing in nursing homes: A tale of two indications. JAGS 2022

• Trends in Antipsychotic and Mood Stabilizer Prescribing in Long-Term Care in the U.S.: 2011-2014 JAMDA 2020

• Efficacy of Gabapentinoids:

• Gabapentinoids for Pain: Potential Unintended Consequences. AFP 2019

• Gabapentin for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews Review. 2017

• The Illegal Marketing Practices by Pharma promoting ineffective:

• The Neurontin Legacy — Marketing through Misinformation and Manipulation NEJM 2009

• Narrative review: the promotion of gabapentin: an analysis of internal industry documents. Annals of IM. 2006