What is the recommended starting dose of gabapentin (Neurontin) for End-Stage Renal Disease (ESRD) patients with impaired renal function for sleep?

Gabapentin Dosing for Sleep in ESRD Patients

For ESRD patients requiring gabapentin for sleep, start with 100-300 mg once daily at bedtime, with a supplemental dose of 125-350 mg after hemodialysis sessions. 1

Dosing Guidelines for ESRD

Gabapentin requires significant dose adjustment in patients with end-stage renal disease due to its renal elimination pathway:

• Starting dose: 100-300 mg once daily (QD) 1
• Post-hemodialysis supplemental dose: 125-350 mg after each hemodialysis session 1

The FDA drug label specifically provides dosing recommendations based on creatinine clearance:

• For patients with creatinine clearance <15 mL/min: 100-300 mg once daily
• Supplemental post-hemodialysis dose should be administered after each 4 hours of hemodialysis 1

Pharmacokinetic Considerations

Gabapentin is primarily eliminated unchanged by the kidneys, making dose adjustment essential in ESRD:

• Elimination half-life increases from 5-9 hours in normal renal function to approximately 132 hours in dialysis patients 2
• During hemodialysis, approximately 35% of gabapentin can be removed, with a hemodialysis clearance of about 142 mL/min 3
• After hemodialysis, plasma concentrations may increase by approximately 30% due to redistribution 3

Clinical Approach

1. Start low: Begin with 100 mg once daily at bedtime
2. Monitor closely: Watch for signs of efficacy and adverse effects
3. Titrate cautiously: If needed and tolerated, increase by 100 mg increments
4. Add post-dialysis dose: Administer 125-350 mg after each hemodialysis session 1

Potential Adverse Effects

Be vigilant for adverse effects, which are more common in ESRD patients due to drug accumulation:

• Dizziness (most common)
• Somnolence
• Confusion or altered mental status
• Ataxia
• Peripheral edema 2

Important Cautions

• Overdosing in ESRD patients can lead to severe neurological symptoms that may be mistaken for other conditions 2
• Drug monitoring should be considered when available to avoid unintended overdose
• Symptoms of overdose typically resolve with discontinuation of the medication 2

Alternative Options

If gabapentin is not tolerated, pregabalin may be considered as an alternative at a starting dose of 25-75 mg once daily for ESRD patients, with similar post-hemodialysis supplementation 4, 5.

Remember that the elimination half-life of gabapentin is significantly prolonged in ESRD patients (132 hours vs. 5-9 hours in normal renal function), making conservative dosing and careful monitoring essential 3.