Gabapentin Titration Schedule for Neuropathic Pain
The recommended titration schedule for gabapentin (Neurontin) should start with 100-300 mg at bedtime or 100-300 mg three times daily, with gradual increases of 100-300 mg every 1-7 days as tolerated, typically reaching an effective dose of 1800-3600 mg/day in divided doses. 1, 2
Initial Dosing and Titration
- Day 1: Start with 100-300 mg at bedtime or 100-300 mg three times daily
- Days 2-7: Increase by 100-300 mg every 1-7 days as tolerated
- Week 2-4: Continue gradual titration to reach target dose
This slow titration helps minimize side effects such as dizziness and somnolence, which are typically dose-dependent and often transient 1.
Target Dosing
- Effective dose range: 1800-3600 mg/day in 3 divided doses
- Typical maintenance dose: 300-600 mg three times daily
- Maximum recommended dose: 3600 mg/day
- Duration of adequate trial: 3-8 weeks for titration plus 2 weeks at maximum dose 1
The FDA label for postherpetic neuralgia recommends initiating gabapentin on Day 1 as a single 300 mg dose, on Day 2 as 600 mg/day (300 mg twice daily), and on Day 3 as 900 mg/day (300 mg three times daily), with subsequent titration up to 1800 mg/day (600 mg three times daily) as needed for pain relief 2.
Dosage Adjustment in Special Populations
Renal Impairment
Dosage adjustment is required based on creatinine clearance 2:
| Creatinine Clearance (mL/min) | Total Daily Dose Range (mg/day) | Dose Regimen |
|---|---|---|
| ≥60 | 900-3600 | 300-1200 mg TID |
| >30-59 | 400-1400 | 200-700 mg BID |
| >15-29 | 200-700 | 200-700 mg QD |
| ≤15 | 100-300 | 100-300 mg QD |
Elderly Patients
- Start with lower doses and titrate more slowly
- Adjust dose based on creatinine clearance values
- Monitor closely for cognitive impairment and sedation 3, 2
Administration Guidelines
- Gabapentin can be taken with or without food
- The maximum time between doses should not exceed 12 hours
- If dividing scored tablets (600 mg or 800 mg), the unused half-tablet should be taken as the next dose and discarded if not used within 28 days 2
Monitoring and Follow-up
- Assess pain relief and functional improvement regularly
- If substantial pain relief is achieved, continue treatment
- If partial pain relief is achieved after an adequate trial, consider adding another first-line medication
- Monitor for adverse effects, particularly excessive sedation 3
Common Side Effects and Management
- Dizziness (19% of patients)
- Somnolence (14%)
- Peripheral edema (7%)
- Gait disturbance (14%) 4
These side effects are typically mild to moderate and often subside within approximately 10 days from the initiation of treatment 5.
Clinical Pearls
- Gabapentin has nonlinear pharmacokinetics due to saturable absorption, making careful titration necessary 1
- An adequate trial may require 2 months or more to determine efficacy 1
- If gabapentin must be discontinued, it should be tapered gradually over a minimum of 1 week to avoid withdrawal symptoms 2
- For patients who don't respond adequately to gabapentin, consider switching to pregabalin, which has more predictable pharmacokinetics and faster onset of action 3
By following this titration schedule, patients are more likely to achieve optimal pain relief while minimizing adverse effects, ultimately improving their quality of life and functional status.