Is gabapentin (GABA analog) used to treat anxiety?

Gabapentin for Anxiety: Evidence-Based Assessment

Gabapentin is not FDA-approved for anxiety disorders but may be considered as a second-line or adjunctive treatment option in specific clinical scenarios when first-line treatments have failed or are contraindicated. 1

Current Evidence on Gabapentin for Anxiety

Regulatory Status and Guidelines

• Gabapentin is not FDA-approved for the treatment of anxiety disorders
• It is primarily approved for seizure control and neuropathic pain 2
• Pregabalin (a similar gabapentinoid) is approved for anxiety in some countries, but gabapentin lacks this specific indication 2

Clinical Evidence

• Limited high-quality evidence supports gabapentin's use specifically for anxiety disorders:
  • One randomized controlled trial showed efficacy in breast cancer survivors with anxiety symptoms 3
  • A placebo-controlled study found benefit only in more severely ill panic disorder patients 4
  • Case reports suggest potential benefit in generalized anxiety disorder (GAD) 5
  • A systematic review concluded there may be benefit for some anxiety disorders, but no studies specifically for GAD 6

Safety Concerns

• Gabapentinoids have been associated with:
  • Tolerance and dependence issues similar to benzodiazepines 7
  • Risk of withdrawal symptoms with discontinuation 2
  • Potential for misuse, leading to classification as controlled substances in some countries 7
  • Sedation, dizziness, and cognitive effects, particularly in elderly patients 1

Clinical Applications

When Gabapentin Might Be Considered for Anxiety

1. As an adjunctive treatment when first-line therapies (SSRIs, SNRIs, psychotherapy) have failed
2. In patients with comorbid conditions where gabapentin has established efficacy:
   • Neuropathic pain 2
   • Seizure disorders
   • Perioperative anxiety (as part of multimodal analgesia) 2
3. In patients with substance use concerns where benzodiazepines are contraindicated 3
4. For patients experiencing withdrawal from opioids or alcohol 2

Dosing Considerations

• Starting dose: 300 mg daily, typically at bedtime
• Gradual titration based on response and tolerability
• Effective doses typically range from 300-900 mg/day for anxiety symptoms 3
• Dose adjustment required in renal impairment 1

Monitoring and Precautions

• Monitor for sedation, dizziness, and cognitive effects
• Be aware of potential for dependence and withdrawal
• Use with caution in elderly patients or those with renal impairment
• Avoid abrupt discontinuation; taper gradually when stopping 2

Alternative First-Line Treatments for Anxiety

1. SSRIs/SNRIs: Considered first-line pharmacotherapy for most anxiety disorders 2, 1

   • Examples: escitalopram, sertraline, venlafaxine, duloxetine

2. Cognitive Behavioral Therapy (CBT): Evidence-based psychotherapy approach 2

3. Benzodiazepines: For short-term use in acute anxiety, with caution regarding dependence 2

Clinical Bottom Line

While gabapentin shows some promise for anxiety symptoms in specific populations, it should not be considered a first-line treatment for anxiety disorders due to limited high-quality evidence and potential safety concerns. Its use should be reserved for specific clinical scenarios where standard treatments are ineffective, contraindicated, or when treating comorbid conditions for which gabapentin has established efficacy.