What is the appropriate dose of Gabapentin (Gabapentin) in a patient with Chronic Kidney Disease (CKD) stage 4, characterized by Impaired Renal Function?

From the Guidelines

For patients with chronic kidney disease stage 4 (CKD 4), the recommended gabapentin dose should be significantly reduced to 100-300 mg once daily, with a maximum daily dose of 700 mg divided into once or twice daily administration, as dose adjustments are crucial to prevent drug accumulation and toxicity 1.

Gabapentin Dosing in CKD 4

When managing patients with CKD 4, it is essential to consider the reduced renal function and its impact on drug elimination. Gabapentin is primarily eliminated unchanged by the kidneys, which necessitates dose reduction in CKD to prevent accumulation and potential toxicity.

• The starting dose should be between 100-300 mg once daily.
• The maximum daily dose should not exceed 700 mg, divided into once or twice daily administration.
• Dose adjustments should be made gradually, typically increasing by 100 mg every 5-7 days as tolerated, while closely monitoring for side effects such as dizziness, somnolence, peripheral edema, and confusion.
• Renal function should be regularly monitored, as further deterioration would require additional dose adjustments.
• For elderly patients with CKD 4, consider starting at the lower end of the dosing range (100 mg daily) due to increased sensitivity to side effects.

Considerations for Gabapentin Use in CKD 4

Given the potential for significant side effects, especially in the context of reduced renal function, careful consideration and monitoring are necessary when prescribing gabapentin to patients with CKD 4.

• Nighttime dosing may be preferable initially to minimize daytime sedation.
• Regular assessment of renal function and adjustment of the gabapentin dose as needed is crucial to balance efficacy with the risk of adverse effects.
• The choice of gabapentin over other medications for neuropathic pain should be based on the individual patient's profile, including the presence of CKD 4, and the potential benefits and risks associated with its use 1.

From the FDA Drug Label

TABLE 1 Gabapentin Tablets Dosage Based on Renal Function Renal Function Creatinine Clearance (mL/min) Total Daily Dose Range (mg/day) Dose Regimen (mg) ...

15-29 200-700 200 QD 300 QD 400 QD 500 QD 700 QD 15a 100-300 100 QD 125 QD 150 QD 200 QD 300 QD

For a patient with CKD 4, the creatinine clearance is typically between 15-29 mL/min.

• The recommended total daily dose range for gabapentin in this case is 200-700 mg/day.
• The dose regimen can be 200 QD, 300 QD, 400 QD, 500 QD, or 700 QD. 2

From the Research

Gabapentin Dosing in CKD 4

• The ideal gabapentin dose in patients with chronic kidney disease (CKD) stage 4 is not explicitly stated in the provided studies, but it is emphasized that dose adjustments are necessary to prevent toxicity 3, 4, 5, 6, 7.
• Patients with CKD are at risk for gabapentin toxicity due to its exclusive renal elimination, and existing literature on this risk is lacking 3.
• A study found that patients with CKD stage 4 or higher had higher serum gabapentin levels and were more likely to experience toxicity than those with normal kidney function 3.
• Another study suggested that appropriate dosing of gabapentinoids is crucial to minimize the risk of adverse events in patients with CKD, particularly in those with advanced kidney disease 4.
• The risk of adverse events associated with gabapentin and pregabalin use in patients with CKD is dose-dependent, with higher doses increasing the risk of altered mental status, falls, and fractures 5, 7.
• Current recommendations for pain management in CKD and end-stage kidney disease emphasize the use of non-opioid analgesics, including gabapentinoids, with careful dose considerations in kidney disease 6.

Key Considerations

• Gabapentin dose should be adjusted according to kidney function to prevent toxicity 3, 4, 5, 6, 7.
• Patients with CKD stage 4 or higher require careful monitoring and dose adjustment due to the increased risk of adverse events 3, 4, 5, 7.
• The use of gabapentinoids should be judicious, and research is needed to identify the most optimal dosing in patients with CKD 5.