What is the recommended dosage and treatment plan for a two-week course of Gabapentin (Gabapentin) for post-operative orthopedic pain?

Gabapentin for Post-Operative Orthopedic Pain Management

Gabapentin is not recommended as a routine treatment for a two-week course of post-operative orthopedic pain management due to limited evidence of efficacy and potential side effects. 1

Recommended Approach

First-Line Treatments

• Use multimodal analgesia with acetaminophen and NSAIDs as the foundation of post-operative pain management
• Consider a single dose of dexamethasone 8 mg IV at induction for improved pain control 1

Role of Gabapentin

• If gabapentin is considered despite the recommendation against routine use:
  • Pre-operative single dose: 300-1200 mg administered 1-2 hours before surgery 2
  • Post-operative dosing: Start at 300 mg TID for 1-3 days, then reassess 2, 3
  • Maximum duration: Limit to 3-5 days to minimize side effects 1, 2

Evidence Analysis

The 2019 expert panel guidelines explicitly state: "The systematic use of gabapentinoids preoperatively is not recommended for postoperative pain management" 1. This recommendation is supported by the PROSPECT guidelines for orthopedic procedures, which found that gabapentinoids show evidence of pain reduction but "are not recommended as routine medication due to clinically relevant side-effects" 1.

Studies examining gabapentin specifically for orthopedic procedures show mixed results:

• A Singapore study found that pre-emptive gabapentin 300 mg reduced pain scores and morphine consumption following lower extremity orthopedic surgery 4
• However, Cochrane reviews indicate gabapentin has limited clinical value in acute postoperative pain with an NNT of 11 for 50% pain relief 5

Side Effects and Monitoring

Common side effects include:

• Sedation and dizziness (most common)
• Visual disturbances
• Increased risk when combined with other CNS depressants 2

The NNH (Number Needed to Harm) for minor adverse events is 3.7 6, meaning approximately 1 in 4 patients will experience side effects.

Special Considerations

• Dose adjustments are required for patients with renal impairment
• Use caution in elderly patients due to increased risk of sedation and falls
• Monitor for excessive sedation when combined with opioids 2

Alternative Approaches

For post-operative orthopedic pain, consider these evidence-based alternatives:

• Local anesthetic infiltration at surgical site
• Regional anesthesia techniques where appropriate
• Low-dose ketamine (0.5 mg/kg/h) for surgeries with high risk of acute pain 1
• Dexamethasone 8 mg IV at induction 1

In conclusion, while gabapentin may provide some analgesic benefit in select orthopedic patients, current guidelines do not support its routine use for a two-week course following orthopedic surgery due to limited efficacy and significant side effect profile.