What is the appropriate management plan for a patient with a history of anxiety, depression, and substance abuse, currently taking gabapentin (Neurontin) 300mg three times daily and hydroxyzine (Vistaril) 50mg twice daily, who is seeking medication refills and considering restarting oxcarbazepine (Trileptal)?

From the Guidelines

The patient's current medication regimen of gabapentin 300mg three times daily and hydroxyzine 50mg twice daily should be continued, but restarting oxcarbazepine (Trileptal) is not recommended due to the lack of clear evidence supporting its use in this patient's specific condition 1. The patient's history of anxiety, depression, and substance abuse requires careful consideration of their medication regimen. Gabapentin, a calcium channel alpha-delta ligand, has been shown to be effective in managing neuropathic pain, with a recommended starting dosage of 100-300 mg at bedtime or 100-300 mg three times daily, and a maximum dosage of 3-8 weeks for titration plus 2 weeks at maximum dose 1.

• The patient is currently taking gabapentin 300mg three times daily, which is within the recommended dosage range.
• Hydroxyzine, an antihistamine, is often used to manage anxiety, and the patient's current dosage of 50mg twice daily is a common regimen.
• Oxcarbazepine (Trileptal), an anticonvulsant, is not mentioned in the provided evidence as a recommended medication for the patient's specific conditions, and its use may be associated with potential interactions or side effects. The plan should include:
• Continuing the current medication regimen of gabapentin 300mg three times daily and hydroxyzine 50mg twice daily.
• Monitoring the patient's symptoms and adjusting the medication regimen as needed.
• Scheduling a follow-up appointment to assess the effectiveness of the current medication regimen and to discuss potential alternative treatments.
• Encouraging the patient to continue attending therapy and to consider seeking additional support from an outpatient psychiatrist.

From the FDA Drug Label

Dosage and Administration 2. 1 Dosage for Postherpetic Neuralgia In adults with postherpetic neuralgia, gabapentin may be initiated on Day 1 as a single 300 mg dose, on Day 2 as 600 mg/day (300 mg two times a day), and on Day 3 as 900 mg/day (300 mg three times a day). The starting dose is 300 mg three times a day. The recommended maintenance dose of gabapentin tablets is 300 mg to 600 mg three times a day. If the gabapentin dose is reduced, discontinued, or substituted with an alternative medication, this should be done gradually over a minimum of 1 week (a longer period may be needed at the discretion of the prescriber).

The patient's current gabapentin dose of 300mg three times daily is within the recommended maintenance dose range. No changes to the gabapentin dose are necessary. When considering restarting oxcarbazepine (Trileptal), caution should be exercised due to the patient's history of substance abuse. Close monitoring of the patient's condition and regular follow-up appointments are recommended to assess the effectiveness of the current medication regimen and potential interactions with oxcarbazepine. Gradual dose adjustments should be made if necessary, and the patient should be informed of the potential risks and benefits of restarting oxcarbazepine 2.

From the Research

Patient Management Plan

To develop an appropriate management plan for the patient, several factors must be considered, including their history of anxiety, depression, and substance abuse, as well as their current medication regimen and the potential risks associated with restarting oxcarbazepine (Trileptal) 3.

Medication Review

A systematic review of the patient's medication regimen is necessary to identify potential problems, such as adverse effects, drug-drug interactions, and drug-disease interactions 3. The patient is currently taking gabapentin (Neurontin) 300mg three times daily and hydroxyzine (Vistaril) 50mg twice daily. Gabapentin has been associated with an increased risk of suicidal thoughts and behaviors, particularly in patients with a history of psychiatric disorders 4, 5.

Risk of Suicidal Behavior

The risk of suicidal behavior associated with gabapentin and other anticonvulsant medications, including oxcarbazepine, must be carefully considered 5, 6. Oxcarbazepine has been shown to have a higher incidence of completed suicides, attempted suicides, and violent deaths compared to other anticonvulsants 5.

Key Considerations

• The patient's history of anxiety, depression, and substance abuse increases their risk of suicidal behavior 4, 5.
• Gabapentin has been associated with an increased risk of suicidal thoughts and behaviors, particularly in patients with a history of psychiatric disorders 4, 5.
• Oxcarbazepine has a higher incidence of completed suicides, attempted suicides, and violent deaths compared to other anticonvulsants 5.
• The patient's medication regimen should be carefully reviewed to identify potential problems, such as adverse effects, drug-drug interactions, and drug-disease interactions 3.
• Close monitoring of the patient's mental health and suicidal ideation is necessary when prescribing gabapentin or oxcarbazepine 4, 5, 6.

Potential Interactions and Risks

• The patient's current medication regimen, including gabapentin and hydroxyzine, should be evaluated for potential interactions with oxcarbazepine 3.
• The risk of intentional drug overdose involving gabapentinoids, including gabapentin and oxcarbazepine, should be considered 7.
• The patient's pharmacist can be an excellent resource for determining appropriate dosages, potential for interaction, and overlapping drugs 3.