Gabapentin Post-Operative Regimen Recommendations
For post-operative pain management, gabapentin should be limited to a single lowest preoperative dose, unless specifically indicated for postoperative neuropathic pain, with dose adjustments based on age and renal function. 1
Recommended Dosing Regimen
Initial Dosing
- Preoperative dose: Single 300 mg dose administered before surgery 2
- First 1-2 days post-op: 300 mg once or twice daily 3
- Days 3-5: Taper off gabapentin as pain decreases 1
- Maximum duration: 5-7 days post-operatively 1, 2
Dose Adjustments
- Elderly patients (>65 years): Reduce dose to 100-200 mg due to increased sensitivity 1, 3
- Renal impairment:
- CrCl >30-59 mL/min: 200-300 mg twice daily
- CrCl >15-29 mL/min: 200-300 mg once daily
- CrCl <15 mL/min: 100-200 mg once daily 3
Evidence-Based Rationale
The 2019 Enhanced Recovery After Surgery (ERAS) guidelines recommend gabapentinoids as part of multimodal analgesia but emphasize limiting their use to a single lowest preoperative dose to avoid sedative side effects 1. This recommendation is supported by meta-analyses showing that while gabapentin reduces postoperative pain and opioid consumption, these benefits are offset by increased sedation, dizziness, and visual disturbances 1.
The 2021 British Journal of Anaesthesia guidelines on perioperative opioid use support a limited duration of gabapentinoid use, recommending that patients on gabapentinoids be identified and the indications reviewed, with tapering if no longer indicated 1.
Administration Considerations
- Administer gabapentin orally with or without food 3
- Combine with other non-opioid analgesics (paracetamol, NSAIDs) as part of multimodal analgesia 1
- Monitor for side effects, particularly:
- Sedation
- Dizziness
- Visual disturbances 1
Special Considerations
Major vs. Minor Surgery
- Major surgery: Consider paravertebral blocks or other regional techniques instead of or in addition to gabapentin 1
- Minor surgery: Local anesthetic infiltration plus gabapentin may be sufficient 1
Risk of Prolonged Use
Gabapentin should be tapered if no longer indicated after the immediate post-operative period 1. The FDA label does not specifically address post-operative use, but the dosing guidelines for other indications suggest gradual dose increases and reductions 3.
Monitoring and Follow-up
- Assess pain scores and sedation levels daily
- Reduce dose if excessive sedation occurs
- Begin tapering gabapentin before other analgesics when pain decreases (reverse analgesic ladder) 1
- Monitor for synergistic effects with opioids that could increase sedation 1
Limitations of Evidence
The Cochrane review found that gabapentin 250 mg is statistically superior to placebo for acute postoperative pain but has limited clinical value as a stand-alone analgesic 4. Multiple dosing regimens may be more beneficial than single doses for reducing both acute and chronic post-operative pain 5, but this must be balanced against the risk of side effects.
While gabapentin has demonstrated efficacy for certain neuropathic pain conditions 6, 7, its role in routine post-operative pain management should be limited to short-term use at the lowest effective dose to minimize adverse effects while providing opioid-sparing benefits.