Is gabapentin (Neurontin) safe to use in patients with chest pain?

Gabapentin Use in Patients with Chest Pain

Gabapentin is generally safe to use in patients with chest pain, particularly when the chest pain is neuropathic in origin, but caution should be exercised in patients with cardiac conditions due to potential side effects like peripheral edema.

Safety Profile of Gabapentin in Chest Pain

• Gabapentin is recommended for neuropathic pain conditions and has been shown to be effective for various types of chronic pain, including post-sternotomy chest pain and paresthesia 1.
• In a randomized controlled trial specifically examining chest pain after sternotomy, gabapentin (800 mg/day) was found to be superior to diclofenac in reducing both pain and paresthesia, with minimal side effects (7% of patients) 1.
• Gabapentin is not contraindicated for use in patients with chest pain of cardiac origin, as guidelines for acute coronary syndromes and chest pain management do not list gabapentin among medications to avoid 2.

Considerations for Different Types of Chest Pain

Neuropathic Chest Pain

• Gabapentin is a first-line oral pharmacological treatment for neuropathic pain conditions 2.
• For post-sternotomy chest pain (which often has neuropathic components), gabapentin has demonstrated superior efficacy compared to NSAIDs 1.
• A typical adult regimen will titrate to 2400 mg per day in divided doses for neuropathic pain 2.

Cardiac-Related Chest Pain

• For chest pain of suspected cardiac origin, immediate medical attention should be prioritized, with aspirin administration being the recommended first-line intervention while waiting for emergency services 2.
• Gabapentin is not mentioned as a treatment for acute cardiac chest pain in guidelines, as it does not address the underlying ischemia 2.
• When prescribing gabapentin to patients with cardiac conditions, be aware that:
  • There have been case reports of possible heart failure associated with pregabalin and gabapentin use, particularly in elderly patients with cardiac history 3.
  • Peripheral edema is a known side effect of gabapentin, occurring in approximately 7% of patients 4.

Dosing and Monitoring Recommendations

• Start with lower doses (300-600 mg/day) and gradually titrate up to minimize side effects 2.
• Monitor for common adverse effects, which include:
  • Dizziness (19% of patients) 4
  • Somnolence (14% of patients) 4
  • Peripheral edema (7% of patients) 4
  • Gait disturbance (9% of patients) 4
• For patients with known cardiac conditions, monitor for signs of fluid retention or worsening cardiac function 3.

Special Considerations

• Gabapentin may be particularly useful for chest pain with neuropathic features (burning, shooting, or electrical sensations) 2.
• In patients with multiple pain conditions, gabapentin may provide benefits for comorbid conditions like fibromyalgia 2.
• Serious adverse events with gabapentin are not significantly more common than with placebo (3.2% vs 2.8%) 4.
• Avoid abrupt discontinuation; taper gradually to prevent withdrawal symptoms 2.

Conclusion for Clinical Practice

• For neuropathic chest pain: Gabapentin is an appropriate and effective treatment option 1, 5.
• For chest pain of cardiac origin: Address the underlying cardiac condition first; gabapentin may be used concurrently for comorbid neuropathic pain but monitor for fluid retention 2, 3.
• For chest pain of unknown origin: Ensure proper cardiac evaluation before initiating gabapentin for symptom management 2.