What is the recommended dose and frequency of gabapentin (Neurontin) for the treatment of a pinched nerve?

Gabapentin Dosing for Pinched Nerve (Neuropathic Pain)

Start gabapentin at 100-300 mg at bedtime on day 1, increase to 300 mg three times daily (900 mg/day) by day 3, then titrate upward by 300 mg every 3-7 days until reaching the target therapeutic dose of 1800-3600 mg/day in three divided doses. 1, 2

Initial Dosing Strategy

• Day 1: Begin with 100-300 mg at bedtime 1, 2
• Day 2: Increase to 600 mg/day (300 mg twice daily) 3
• Day 3: Advance to 900 mg/day (300 mg three times daily) 3
• This rapid initial titration schedule (reaching 900 mg/day by day 3) is supported by clinical trial evidence and provides a foundation for further dose escalation 3

Therapeutic Dose Titration

• After reaching 900 mg/day, continue increasing by 100-300 mg increments every 1-7 days as tolerated 1, 2
• Target dose: 1800 mg/day (600 mg three times daily) is the minimum effective dose for most neuropathic pain conditions 1, 3
• Maximum dose: 3600 mg/day (1200 mg three times daily) may be needed for optimal pain relief 1, 2, 4
• The dose should be divided into three daily administrations due to gabapentin's nonlinear, saturable absorption pharmacokinetics 1

Duration of Adequate Trial

• Allow 3-8 weeks for complete titration plus an additional 2 weeks at the maximum tolerated dose before determining treatment failure 1
• An adequate therapeutic trial may require 2 months or more to achieve optimal effect 1, 2
• Efficacy for neuropathic pain develops gradually over several weeks 2

Expected Outcomes

• At doses of 1800-3600 mg/day, approximately 32-38% of patients achieve substantial benefit (at least 50% pain reduction) compared to 17-21% with placebo 4
• About 46-52% achieve moderate benefit (at least 30% pain reduction) versus 25-37% with placebo 4
• This means 3-4 out of 10 patients will achieve clinically meaningful pain relief 4

Special Population Considerations

Elderly or Medically Frail Patients

• Use slower titration with increases every 3-7 days (rather than 1-3 days) 1, 2
• Consider starting at the lower end of the dosing range (100 mg at bedtime) 2

Renal Impairment

• Mandatory dose reduction is required based on creatinine clearance 1, 2
• Gabapentin is eliminated primarily by renal excretion, necessitating adjustments in patients with reduced kidney function 1

Common Side Effects and Management

• Dizziness (19%) and somnolence (14%) are the most common adverse effects 4
• These side effects are typically mild to moderate and often resolve within approximately 10 days from initiation 3
• Starting with lower doses and gradual titration significantly reduces the incidence and severity of these effects 1, 3
• Peripheral edema (7%) and gait disturbance (14%) also occur but less frequently 4

Critical Pitfalls to Avoid

• Do not use once-daily or twice-daily dosing for standard gabapentin—three times daily administration is essential due to saturable absorption 1
• Do not rush titration in elderly patients, as this increases fall risk from dizziness 1, 2
• Do not discontinue abruptly—taper gradually over at least 1 week to avoid withdrawal symptoms 5
• Do not abandon treatment prematurely—allow the full 2-month trial period before declaring treatment failure 1

Comparison with Pregabalin

• If gabapentin proves ineffective or poorly tolerated, pregabalin offers an alternative with linear pharmacokinetics and more straightforward dosing 1, 5
• Pregabalin can be started at 150 mg/day and titrated to 300-600 mg/day in 2-3 divided doses 1, 5
• Pregabalin may provide faster onset of analgesia due to predictable absorption and ability to start at an effective dose 1