The likelihood of considerable harms from gabapentinoid treatment in contrast to limited demonstrated benefit for various indications suggests that a substantial portion of patients may benefit from deprescribing.
NICE guidance recommends that stopping a gabapentinoid should be considered if: 1
NHS guidance specifically suggests that patients prescribed gabapentinoids for chronic neuropathic pain should have a trial reduction of medication considered every 6 to 12 months in order to establish whether the pain is still an issue, whether the gabapentinoid is beneficial and to determine whether it is causing adverse (side) effects. 2
There are specific groups in whom deprescribing may be of a higher priority including:
However, as for previous chapters on benzodiazepines and z-drugs, there are a variety of reasons why stopping gabapentinoids may be beneficial for a wider group of patients.
There is no formal recommendation for a minimum period of treatment with a gabapentinoid - nor recommendations for a maximum duration of treatment. This lack of recommendations and clinical inertia can lead to patients being prescribed these medications indefinitely. Although not studied for gabapentinoids in particular, it is known from other drug classes that this uncertainty leads to a situation where both patient and prescriber is expecting the other to lead on discussing stopping. 5 There is also fear about 'rocking the boat'. 5 It has been suggested that short-term use of pregabalin in anxiety as a crisis measure only, analogous to benzodiazepines, may be warranted. 6 The NICE guidelines on safe withdrawal encourage clinicians to regularly review patients taking gabapentinoids and to consider deprescribing. 1
There has been little work performed on the best approach to stopping gabapentinoids. 7 Those few studies have focused on educational interventions to inform patients about the possibility of deprescribing. 7 In one study highlighting opportunities for deprescribing, provision of information and tapering instructions to clinicians in an in-patient setting increased deprescribing rates for gabapentinoids in older patients from 21% to 35%. 8
General principles from deprescribing in other drug classes may also be applicable. 9 Education of patients about the risks, benefits and alternatives to these drugs can help motivate patients to stop. 10 Many patients will be unaware of the wide variety of adverse effects of these medications and so may not have attributed these symptoms to the medication, especially after long-term use. Adverse effects of psychotropic drugs are often insidious, and patients may struggle to compare present symptoms with a pre-treatment baseline. This material can be presented in a written format, with some studies in similar medication classes showing that a face-to-face discussion can enhance effectiveness. 11 Patients should have it explained to them that their anxiety or pain may not worsen if the drug is reduced in dose because of a lack of evidence for effectiveness, especially in the long-term, due to tolerance effects.
Outlining a gradual and flexible taper involving tolerable dose-reductions (see subsequent sections) may help alleviate fears patients have about the process. Patients with specific fears relating to prior unsuccessful attempts to stop medications may be reassured that reducing doses more carefully can help to avoid severe withdrawal symptoms. Patients may have falsely come to believe that their medication is helpful for pain or anxiety because when they stop it they experience worsening of these symptoms - and conversely when they take a dose they experience an improvement in anxiety or pain. Sometimes this relief may be caused by improvement of withdrawal symptoms (which can include depressed mood, anxiety and pain) 12, 13 rather than direct evidence of their effectiveness for underlying conditions, analogous to the situation for benzodiazepines. If alternative means for managing pain or anxiety are available, for example, physiotherapy, psychological therapy or support, this may also give a patient greater confidence in stopping, and help to manage the issues that prompted the prescription in the first place.