What is the recommended dosing regimen for gabapentin (Gabapentin) in the treatment of alcohol use disorder?

Gabapentin Dosing for Alcohol Use Disorder Treatment

The recommended dosing regimen for gabapentin in the treatment of alcohol use disorder is 900-1800 mg/day in divided doses, with 1800 mg/day showing the greatest efficacy for abstinence and reduction in heavy drinking. 1

Initial Dosing and Titration

• Starting dose: 300 mg three times daily (900 mg/day) or start lower and titrate up
• Titration schedule: Increase by 300 mg every 1-7 days as tolerated
• Target dose: 1800 mg/day (600 mg three times daily)
• Maximum dose: 1800 mg/day for AUD (higher doses increase risk of adverse effects)

Evidence for Efficacy

Gabapentin has demonstrated dose-dependent efficacy in treating alcohol use disorder:

• At 1800 mg/day:

  • 17% abstinence rate (vs. 4.1% with placebo)
  • 44.7% no heavy drinking rate (vs. 22.5% with placebo)
  • Number needed to treat (NNT) of 5 for preventing heavy drinking 1

• At 900 mg/day:

  • 11.1% abstinence rate
  • 29.6% no heavy drinking rate 1

Benefits Beyond Abstinence

Gabapentin also provides dose-dependent improvement in alcohol-related symptoms:

• Reduces insomnia
• Decreases dysphoria/improves mood
• Reduces alcohol craving 1

Safety Considerations

1. Renal function:

   • Dose adjustment required for creatinine clearance <60 mL/min 2
   • For CrCl 30-59 mL/min: reduce to 150-300 mg/day
   • For CrCl 15-29 mL/min: reduce to 75-150 mg/day

2. Risk of falls and altered mental status:

   • Increased risk of falls/fractures with doses ≥600 mg/day
   • Clear dose-response relationship with highest risk at ≥2400 mg/day 3
   • Monitor for altered mental status, especially during titration

3. Liver disease:

   • Unlike naltrexone and disulfiram, gabapentin has no hepatic metabolism
   • Can be used in patients with alcoholic liver disease 4
   • Monitor closely for worsening mental status/sedation in patients with liver disease 4

4. Elderly patients:

   • Use lower starting doses and slower titration 2

Treatment Duration and Monitoring

• Minimum treatment duration: 12 weeks (based on clinical trial data) 1
• Follow-up: Every 2-4 weeks during titration to assess efficacy and side effects
• Monitor for:
  • Sedation (especially first 48 hours)
  • Falls risk
  • Alcohol consumption patterns
  • Improvement in sleep and mood

Comparison with Other AUD Medications

While FDA-approved medications (naltrexone, acamprosate, disulfiram) are first-line options for AUD, gabapentin offers several advantages:

• No hepatic metabolism (unlike naltrexone and disulfiram)
• Beneficial effects on alcohol withdrawal symptoms
• Addresses comorbid insomnia and mood symptoms
• Can be used in patients with liver disease 4

Clinical Pearls

1. The 1800 mg/day dose shows substantially better efficacy than 900 mg/day
2. Divided dosing (three times daily) is recommended for better tolerability
3. Gabapentin should not be abruptly discontinued due to risk of withdrawal symptoms
4. Gabapentin may increase the abuse liability of alcohol in some patients 5
5. Consider as an alternative to baclofen in patients with AUD and liver disease

Gabapentin represents a valuable non-FDA approved option for AUD treatment, particularly in patients with liver disease, insomnia, or mood symptoms associated with alcohol use.