What are the withdrawal effects of Gabapentin (Neurontin)?

From the Guidelines

Gabapentin withdrawal can cause significant symptoms when stopped abruptly, so tapering is strongly recommended. Common withdrawal effects include anxiety, insomnia, headaches, nausea, sweating, and in severe cases, seizures or status epilepticus, as highlighted in a study published in The Lancet Psychiatry 1. These symptoms typically begin within 12-48 hours after the last dose and may last for up to a week or longer. To minimize withdrawal, patients should gradually reduce their dose over at least 1-2 weeks, with longer tapers (3-4 weeks or more) for those on higher doses or who have been taking it long-term. For example, a patient on 1800mg daily might reduce by 300mg every 3-4 days.

Some key points to consider when managing gabapentin withdrawal include:

• The risk of physical and psychological withdrawal symptoms with sudden cessation, as noted in a study published in The Lancet Psychiatry 1
• The importance of careful tapering and support for patients treated long-term with gabapentinoids
• The need for improved guidance, monitoring, and effective patient care to minimize the risk of withdrawal symptoms
• The potential for severe withdrawal symptoms, such as seizures or status epilepticus, in patients with a history of seizures, anxiety disorders, or substance use disorders

Withdrawal occurs because gabapentin affects GABA neurotransmission and calcium channels in the brain; with prolonged use, the brain adapts to these effects, and sudden discontinuation disrupts this new equilibrium. Patients with a history of seizures, anxiety disorders, or substance use disorders may be at higher risk for severe withdrawal and should be monitored closely during the tapering process. If severe withdrawal symptoms develop, resuming the previous dose and implementing a slower taper is advisable, as suggested by the evidence 1.

From the FDA Drug Label

There are rare postmarketing reports of individuals experiencing withdrawal symptoms shortly after discontinuing higher than recommended doses of gabapentin used to treat illnesses for which the drug is not approved. Such symptoms included agitation, disorientation and confusion after suddenly discontinuing gabapentin that resolved after restarting gabapentin Adverse reactions following the abrupt discontinuation of gabapentin have also been reported. The most frequently reported reactions were anxiety, insomnia, nausea, pain, and sweating.

Withdrawal effects of gabapentin may include:

• Agitation
• Disorientation
• Confusion
• Anxiety
• Insomnia
• Nausea
• Pain
• Sweating These symptoms have been reported in individuals taking higher than recommended doses of gabapentin, particularly when the drug is discontinued abruptly 2, 2.

From the Research

Withdrawal Effects of Gabapentin

• Gabapentin has been reported to cause severe physiologic dependence and withdrawal, although it is usually well tolerated 3.
• The withdrawal symptoms of gabapentin can be similar to those of alcohol withdrawal and benzodiazepines, and can be life-threatening 3, 4.
• Tapering gabapentin in patients with severe dependence and withdrawal poses a significant clinical challenge, with little published information to date on meeting this challenge 3.
• A patient-centered slow taper, such as the BRAVO Protocol, can be an effective strategy for tapering gabapentin in patients with severe dependence and withdrawal 3.
• The BRAVO Protocol, originally developed for opioids and adapted to benzodiazepines, provides a framework for a gabapentin taper, and can be a practical and compassionate approach for patients with severe gabapentin dependence and withdrawal 3.

Comparison with Benzodiazepines

• Benzodiazepines, like gabapentin, can cause severe dependence and withdrawal, and require careful tapering when prescribed 4.
• The withdrawal symptoms of benzodiazepines can be similar to those of gabapentin, and can be life-threatening 4.
• The treatment for benzodiazepine withdrawal is typically through tapering with clonazepam, although other drugs have been tested as alternative treatments 4.
• Gabapentin and benzodiazepines can have similar anxiolytic effects, although gabapentin may have a different mechanism of action 5, 6.

Clinical Considerations

• Gabapentin can be used to treat a range of conditions, including post-herpetic neuralgia, peripheral neuropathy, seizure disorders, alcohol use disorder, and insomnia 3.
• The use of gabapentin in mood disorders, such as bipolar disorder, has been studied, and it may have mood-stabilizing properties 5, 6.
• The pharmacology and classification of gabapentin, as well as its efficacy and adverse effects, should be considered when prescribing it for any condition 7.