Can gabapentin be used to treat Alcohol Use Disorder (AUD)?

Gabapentin for Alcohol Use Disorder (AUD)

Gabapentin is not recommended as a first-line treatment for alcohol use disorder due to inconsistent evidence of efficacy and potential safety concerns. 1

Efficacy and Evidence Assessment

Gabapentin has been studied for AUD treatment with mixed results:

• According to the European Association for the Study of the Liver (EASL) guidelines, gabapentin has been tested for relapse prevention in AUD, but "no consistent results in large samples have been reported" 1
• The French Association for the Study of the Liver notes that gabapentin is available without marketing authorization for AUD treatment, but its "tolerance profile is not considered harmless" and requires "careful assessment of the benefit-risk ratio" 1
• Meta-analyses show gabapentin may reduce the percentage of heavy drinking days, but the magnitude of benefit is small with no benefits for other drinking outcomes 2

Safety Concerns

Several important safety considerations exist:

• Risk of dependence and withdrawal: Case reports document severe physiologic dependence requiring extended tapering periods (up to 18 months in one case) 3
• Increased risk of adverse events: A large cohort study of 571,718 veterans found gabapentin was associated with:
  • Higher incidence of falls or fractures (1.81 vs 1.34 per 100 person-years)
  • Increased risk of altered mental status
  • Clear dose-response relationship with highest risk at doses ≥2,400 mg/day 4

Current Place in AUD Treatment Algorithm

1. First-line FDA-approved medications should be prioritized:

   • Naltrexone
   • Acamprosate
   • Disulfiram

2. Consider gabapentin only when:

   • First-line medications cannot be used 2
   • Patient has specific comorbidities that might benefit from gabapentin (chronic pain, anxiety, insomnia) 2
   • Patient has high alcohol withdrawal symptoms, as some evidence suggests better response in this subgroup 2

3. Avoid gabapentin in:

   • Patients with severe hepatic or renal impairment
   • Elderly patients due to increased fall risk
   • Patients with history of substance use disorders beyond alcohol

Important Clinical Considerations

• Dosing for AUD typically starts at 900 mg/day 2
• Monitor closely for adverse effects, especially at doses ≥600 mg/day 4
• Non-pharmacological management remains the most relevant element of AUD treatment 1
• Brief interventions using the "five A's" model should be incorporated:
  • Ask about use
  • Advise to quit or reduce
  • Assess willingness
  • Assist to quit or reduce
  • Arrange follow-up 1

Conclusion

While gabapentin may have a limited role in AUD treatment, particularly for patients with specific comorbidities or those who cannot use first-line medications, the evidence supporting its use is inconsistent and safety concerns exist. Treatment decisions should prioritize FDA-approved medications with stronger evidence bases.