What is the safest way to discontinue gabapentin (Neurontin) after 10 years of use at a dose of 2400mg per night?

Safe Discontinuation of Gabapentin After Long-Term Use

Gabapentin should be tapered very gradually over a period of several months to minimize withdrawal symptoms, with dose reductions of approximately 100-300 mg every 1-2 weeks initially, followed by smaller reductions of 50-100 mg every 1-2 weeks as the dose decreases.

Understanding Gabapentin Withdrawal Risk

Long-term use of gabapentin at high doses (2400 mg/day for 10 years in this case) creates significant physical dependence. Abrupt discontinuation can lead to potentially serious withdrawal symptoms including:

• Anxiety and agitation
• Insomnia
• Diaphoresis (excessive sweating)
• Palpitations
• Nausea and gastrointestinal distress
• Mental status changes
• Seizures and status epilepticus in severe cases 1
• Akathisia (restlessness) 2

Recommended Tapering Protocol

Initial Assessment

• Confirm the indication for gabapentin and whether continued therapy is necessary
• Assess renal function as this affects dosing and potentially the tapering schedule 3
• Evaluate for comorbid conditions that might complicate withdrawal

Tapering Schedule

1. Initial Phase (Months 1-3)

   • Begin with a reduction of 300 mg per week (10-15% of total daily dose)
   • Example: 2400 mg → 2100 mg → 1800 mg → 1500 mg (over first month)

2. Middle Phase (Months 4-6)

   • Slow to 100-200 mg reductions every 1-2 weeks
   • Example: 1500 mg → 1300 mg → 1100 mg → 900 mg → 700 mg (over second and third months)

3. Final Phase (Months 7-12+)

   • For doses below 600 mg, reduce by 50-100 mg every 1-2 weeks
   • For the final 300 mg, consider even smaller reductions of 25-50 mg every 1-2 weeks
   • The final 100 mg may require extremely slow tapering (5-10 mg decrements) 4

Special Considerations

• Elderly patients require more gradual tapering due to increased sensitivity to medication changes 3
• Renal impairment may require adjusted tapering schedule based on creatinine clearance 3
• For patients with history of seizures, consider overlapping with an alternative anticonvulsant before complete discontinuation

Monitoring During Taper

• Schedule follow-up visits every 2-4 weeks during the taper 5

• Assess for withdrawal symptoms at each visit:

  • Anxiety, insomnia, agitation
  • Pain exacerbation
  • Seizure activity
  • Vital sign changes (particularly blood pressure)
  • Mental status changes

• If withdrawal symptoms occur, temporarily pause the taper and consider:

  • Returning to the previous well-tolerated dose
  • Resuming the taper with smaller decrements
  • Extending the time between dose reductions

Managing Withdrawal Symptoms

• For anxiety/agitation: Consider temporary use of non-benzodiazepine anxiolytics
• For sleep disturbances: Recommend sleep hygiene measures and possibly short-term use of non-benzodiazepine sleep aids
• For pain exacerbation: Consider alternative pain management strategies such as duloxetine or tricyclic antidepressants 5

Common Pitfalls to Avoid

1. Tapering too quickly: Evidence suggests that even a one-week taper can produce withdrawal symptoms in long-term users 6
2. Underestimating dependence: The BRAVO Protocol framework (originally developed for opioids and benzodiazepines) may be adapted for gabapentin tapering in cases of severe dependence 4
3. Failing to recognize withdrawal: Symptoms may be misattributed to other conditions
4. Stopping the taper prematurely: Some patients may require 12-18 months for complete discontinuation 4

When to Slow or Pause the Taper

• If the patient experiences intolerable withdrawal symptoms
• During periods of significant life stress
• If breakthrough seizures occur
• If there is significant worsening of the original condition being treated

The evidence strongly suggests that for a patient on 2400 mg of gabapentin for 10 years, an extended taper over several months is the safest approach to minimize withdrawal symptoms and ensure patient safety.