What is the recommended dosing of gabapentin (Neurontin) for elderly patients with herpes zoster (shingles)?

From the Guidelines

For elderly patients with herpes zoster (shingles), gabapentin (Neurontin) is typically started at a lower dose of 100-300 mg at bedtime or 100-300 mg 3 times daily, with gradual increases as tolerated, considering impaired renal function in this population. When managing neuropathic pain in elderly patients, it's crucial to consider the potential for decreased renal function, which can affect the dosing of gabapentin 1. The dosing strategy for gabapentin in elderly patients with shingles involves starting with a low dose and gradually increasing it, with the goal of achieving adequate pain relief while minimizing adverse effects. Key considerations include:

• Starting dose: 100-300 mg at bedtime or 100-300 mg 3 times daily
• Titration: Increase by 100-300 mg every 1-7 days as tolerated, with careful consideration of renal function
• Maximum dose: Typically not exceeding 1800 mg daily in elderly patients, though this can vary based on individual response and tolerability
• Duration of treatment: Usually 4-8 weeks or until pain resolves, with the possibility of longer treatment if necessary
• Monitoring: Regular assessment for efficacy, tolerability, and potential side effects such as dizziness, somnolence, and peripheral edema, as well as monitoring for increased fall risk, especially during dose titration 1. Given the potential for renal impairment in elderly patients, dose adjustments are necessary to avoid adverse effects, and treatment should be individualized based on patient response and tolerability.

From the FDA Drug Label

In adults with postherpetic neuralgia, gabapentin may be initiated on Day 1 as a single 300 mg dose, on Day 2 as 600 mg/day (300 mg two times a day), and on Day 3 as 900 mg/day (300 mg three times a day). 2.4 Dosage in Elderly Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and dose should be adjusted based on creatinine clearance values in these patients.

The recommended dosing of gabapentin for elderly patients with herpes zoster (shingles) is to start with a single 300 mg dose on Day 1, then 600 mg/day on Day 2, and 900 mg/day on Day 3, with cautious dose selection and adjustment based on creatinine clearance values due to the higher likelihood of decreased renal function in this population 2.

• Key considerations for dosing in elderly patients include:
  • Starting at the low end of the dosing range
  • Adjusting the dose based on renal function
  • Monitoring for adverse reactions, such as peripheral edema and ataxia, which may be more common in older adults 2.

From the Research

Gabapentin Dosing for Elderly Shingles

The recommended dosing of gabapentin for elderly patients with herpes zoster (shingles) can vary depending on the specific condition being treated, such as acute herpetic neuralgia or postherpetic neuralgia.

• For acute herpetic neuralgia, a study published in the Indian Journal of Dermatology 3 found that gabapentin doses of 600 mg/day and 900 mg/day were more effective than 300 mg/day in reducing pain.
• Another study published in JAMA 4 found that gabapentin was effective in reducing pain and sleep interference associated with postherpetic neuralgia, with a maximum dosage of 3600 mg/d.
• However, a study published in Dermatologic Therapy 5 found that low-dose gabapentin (300 mg three times a day) was not effective in preventing postherpetic neuralgia in patients with acute herpes zoster.
• A more recent study published in PLoS One 6 also found that gabapentin did not provide significant relief from acute herpetic pain or prevention of postherpetic neuralgia, with a maximum dosage of 1800 mg/day.

Key Findings

• Gabapentin may be effective in reducing pain associated with acute herpetic neuralgia and postherpetic neuralgia, but the optimal dosage is unclear.
• Higher doses of gabapentin (600 mg/day and 900 mg/day) may be more effective than lower doses (300 mg/day) for acute herpetic neuralgia.
• The use of gabapentin for preventing postherpetic neuralgia is not supported by current evidence 5, 6.
• Gabapentin can cause adverse effects, such as somnolence, dizziness, and peripheral edema, which should be monitored in elderly patients 4, 6.