Gabapentin is in a class of medications called anticonvulsants. Gabapentin treats seizures by decreasing excitement in the brain and has been studied for its effect in patients with cancer who have neuropathic pain or symptoms of peripheral neuropathy. It also has been studied for its effect on anxiety and hot flashes. Gabapentin monotherapy involves use of the drug alone rather than as an adjunctive medication.
The U.S. Food and Drug Administration (FDA) has issued a warning regarding the use of gabapentin or pregabalin and serious breathing difficulties in people with respiratory risk factors, including older adults, those having conditions that reduce lung function such as chronic obstructive pulmonary disease (COPD), and those using drugs that depress the central nervous system including opioids, anti-anxiety medication, antidepressants, and antihistamines.
Arai, Y.C., Matsubara, T., Shimo, K., Suetomi, K., Nishihara, M., Ushida, T., . . . Arakawa, M. (2010). Low-dose gabapentin as useful adjuvant to opioids for neuropathic cancer pain when combined with low-dose imipramine. Journal of Anesthesia, 24, 407–410.
To evaluate the effectiveness of low-dose gabapentin combined with imipramine, in treating cancer-related neuropathic pain
Patients were allocated to four groups. Group 1, consisting of 14 patients, received gabapentin 200 mg and imipramine 10 mg orally every 12 hours; Group 2, consisting of 14 patients, received gabapentin 200 mg orally every 12 hours; Group 3, consisting of 12 patients, received gabapentin 400 mg orally every 12 hours; and Group 4, consisting of 12 patients, received imipramine 10 mg orally every 12 hours. The average intensity of total pain over the past 12 hours was assessed, and the number of paroxysmal pain episodes in the past 24 hours were recorded. Pain was assessed at the first visit and seven days after the beginning of the regimen. Opioid rescue doses were available if needed.
Randomized, controlled trial
Pain was measured on a numeric scale, 1–10.
The total pain scores and daily paroxysmal pain episodes of the patients taking the low-dose gabapentin-imipramine combination (Group 1) decreased significantly (p < 0.05). The combination significantly decreased the previous 24-hour opioid rescue dose. Researchers observed mild adverse symptoms in all four groups. Symptoms included drowsiness, dizziness, and nausea. Note: Three patients dropped out of Group 3 because of adverse effects.
The combination of gabapentin and imipramine in low doses offers a means of successfully treating neuropathic pain, with minimal side effects.
The gabapentin-imipramine combination is effective in treating neuropathic pain caused by nerve compression or invasion of the spinal cord.
Rao, R.D., Michalak, J.C., Sloan, J.A., Loprinzi, C.L., Soori, G.S., Nikcevich, D.A., . . . North Central Cancer Treatment Group. (2007). Efficacy of gabapentin in the management of chemotherapy-induced peripheral neuropathy: A phase 3 randomized, double-blind, placebo-controlled, crossover trial (N00C3). Cancer, 110, 2110–2118.
The purpose of the study was to evaluate the effect of gabapentin on chemotherapy-induced peripheral neuropathy (CIPN).
Patients were assigned to either one of two groups: gabapentin followed by placebo or placebo followed by gabapentin. Doses of both capsules were incrementally increased during the course of three weeks to a target does of 2,700 mg. Patients were treated for six weeks and then had a two-week washout period. After the washout period, patients were treated for another six weeks in the crossover. The sample size was determined by power analysis and study measures were obtained weekly.
The study was conducted at multiple outpatient settings in the north-central region of the United States.
The McGill pain rating questionnaire at six weeks indicated lower pain in the gabapentin-treated groups. No other differences were noted between groups at any point in time during the study. On the numerical scale, a slight reduction in pain was seen in all participants. Improvement was highest in patients who had higher baseline average pain and in those currently in active chemotherapy treatment. Most frequent adverse events were dizziness and fatigue and no differences in adverse events were noted based on gabapentin treatment.
The findings failed to demonstrate any benefit in using gabapentin for CIPN.
The findings do not support the use of gabapentin for the management of CINV.
Takahashi, H., & Shimoyama, N. (2010). A prospective open-label trial of gabapentin as an adjuvant analgesic with opioids for Japanese patients with neuropathic cancer pain. International Journal of Clinical Oncology, 15, 46–51.
To assess the usefulness of gabapentin in the treatment of cancer-related neuropathic pain
Patients who met the eligibility criteria of a score of 5 or greater on a numeric pain rating scale were entered. Gabapentin was begun at baseline at 200 mg and titrated to a maximum dose of 2,400 mg per day. Patients were asked to keep a pain diary and were assessed by a clinician throughout the 15-day study period.
The study was conducted in a single-site inpatient setting in Japan.
This was an open-label, prospective study.
Measurements included a numeric pain rating scale using the Brief Pain Inventory, the McGill Pain Questionnaire, a numeric pain relief scale, and the Patient Global Impression of Change scale.
A significant reduction was noted at various time points for worst, least, and average pain on the numeric scale (p < 0.004). Mean change in scores from baseline ranged from 0.6 to 1.3. No differences were found in any other outcome measure.
A statistical reduction in pain occurred as measured on the five-point numeric rating scale; however, the change was relatively small.
The study findings do not provide strong support for the effectiveness of gabapentin for the management of cancer-related neuropathic pain or other symptoms.
Stubblefield, M.D., Burstein, H.J., Burton, A.W., Custodio, C.M., Deng, G.E., Ho, M., . . . Von Roenn, J.H. (2009). NCCN task force report: Management of neuropathy in cancer. Journal of the National Comprehensive Cancer Network, 7(Suppl., 5), S1–S26.
This study outlines the common antineoplastic agents known to cause neuropathy and provides information on incidence, onset dosages, the signs and symptoms, and general course and patterns of resolution. Agents identified include platinum compounds, vinca alkaloids, taxanes, bortezomib, ixabepilone, thalidomide, and lenalidomide. In addition to outlining the mechanisms of neuropathy development in cancer, the study discusses neurophysiologic and objective testing, noting that findings on electromyographic (EMG) and nerve conduction studies (NCS) can lag behind clinical symptoms. The study also identifies commonly used physician-based grading systems, including the National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) and Eastern Cooperative Oncology Group (ECOG) systems, and notes that these two grading systems lack inter-rater reliability. Patient-based instruments for assessment include the Functional Assessment of Cancer Treatment (FACT) and the Patient Neurotoxicity Questionnaire (PNQ). The authors note that the routine assessment of pain secondary to neuropathy, using instruments such as the Brief Pain Inventory (BPI), is useful.
Routine assessment should be conducted and continued throughout therapy. Key points in assessment that should be included are:
Proposed agents for prevention of CIPN identified include:
Agents used for pain management:
Current literature is inconclusive on the benefits of neurostimulation in treating CIPN. The authors note that evidence is scarce on efficacy of complimentary and alternative medicine (CAM) therapies and the need for appropriately powered and controlled studies in this area. However, acupuncture was identified as a promising adjunct option. The article also provides safety tips and issues for management of functional deficits in PIN, including situations in which to avoid or discontinue physical training, footwear selection, orthosis, and safety aspects of the household environment. Finally, the article addresses how autonomic neuropathy from chemotherapy occurs, but has not been well documented or studied.
The article provides a comprehensive review of current knowledge about CIPN and common approaches toward assessment, prevention, and management. The authors do not make specific recommendations for treatment, research to validate evaluation tools, and exploration of combinations and scheduling of pain medications. In addition, testing of the safety and effectiveness of therapeutic interventions and dietary supplements are needed.