How to dose gabapentin (Neurontin) in patients with Chronic Kidney Disease (CKD)?

Gabapentin Dosing in Chronic Kidney Disease

Gabapentin dosing must be adjusted based on creatinine clearance in patients with chronic kidney disease to prevent toxicity and adverse effects.

Dosing Recommendations Based on Renal Function

Gabapentin is exclusively eliminated by the kidneys and requires careful dose adjustment in CKD patients:

• For patients with creatinine clearance ≥60 mL/min:

  • Standard dosing of 900-3600 mg/day in three divided doses 1
  • Can be given as 300 mg TID, 400 mg TID, 600 mg TID, or 800 mg TID 1

• For patients with creatinine clearance 30-59 mL/min:

  • Reduced dosing of 400-1400 mg/day 1
  • Can be given as 200 mg BID, 300 mg BID, 400 mg BID, 500 mg BID, or 700 mg BID 1

• For patients with creatinine clearance 15-29 mL/min:

  • Further reduced dosing of 200-700 mg/day 1
  • Should be given as 200 mg QD, 300 mg QD, 400 mg QD, 500 mg QD, or 700 mg QD 1

• For patients with creatinine clearance <15 mL/min:

  • Significantly reduced dosing of 100-300 mg/day 1
  • Can be given as 100 mg QD, 125 mg QD, 150 mg QD, 200 mg QD, or 300 mg QD 1

• For hemodialysis patients:

  • Maintenance dose based on estimated creatinine clearance as above 1
  • Plus supplemental post-hemodialysis dose of 125-350 mg after each 4-hour hemodialysis session 1

Clinical Considerations and Monitoring

• Start at the lower end of the dosing range for each CKD stage and titrate slowly based on clinical response 2

• Initiate gabapentin at 100-300 mg at bedtime or 100-300 mg three times daily in patients with impaired renal function 2

• Monitor for signs of gabapentin toxicity, which may include:

  • Dizziness, somnolence, confusion 3
  • Ataxia, myoclonus 3
  • Respiratory depression 4
  • Falls and fractures 4

• Elderly patients with CKD are at higher risk for gabapentin toxicity and should be monitored more closely 3, 4

• Patients with CKD often receive inappropriately high gabapentin dosages for their kidney function, leading to overt toxicity 3

Special Populations

• For elderly patients with CKD:

  • Use extra caution in dose selection 1
  • Adjust dose based on creatinine clearance values 1
  • Consider starting at the lowest possible dose 4

• For patients on peritoneal dialysis:

  • Gabapentin can accumulate to toxic levels with standard dosing 5
  • The elimination half-life increases from 5-9 hours in normal renal function to 132 hours in dialysis patients 5

Important Precautions

• Gabapentin toxicity in CKD patients is often underrecognized, leading to preventable adverse events 3

• Higher-dose gabapentinoid initiation (gabapentin >300 mg/day) in older adults with CKD is associated with a 27% increased risk of hospital visits for encephalopathy, falls, fractures, or respiratory depression compared to lower doses 4

• When discontinuing gabapentin, taper gradually over at least 1 week to minimize withdrawal symptoms 1

• Calculate creatinine clearance using the Cockcroft-Gault equation for accurate dosing 1

By following these dosing guidelines, clinicians can minimize the risk of gabapentin toxicity while maintaining therapeutic efficacy in patients with chronic kidney disease.