Is gabapentin (anticonvulsant) effective for treating itching?

Gabapentin for Itching: Context-Dependent Effectiveness

Gabapentin can be effective for certain types of itching, but should NOT be used for hepatic pruritus and is best reserved for uremic pruritus, opioid-induced pruritus, neuropathic pruritus, and generalized pruritus of unknown origin when first-line treatments fail.

When to Use Gabapentin

Uremic Pruritus (Strongest Evidence)

• Gabapentin is highly effective for uremic pruritus in chronic kidney disease patients, with 66% response rate as monotherapy and 85% when combined with pregabalin as an alternative 1
• Start with 100 mg after each dialysis session (or daily in non-dialysis CKD patients), titrating based on response and tolerability 1
• Reduces itch severity from median score of 8/10 to 1/10 within 1-8 months 1
• Pregabalin 75 mg daily is equally effective if gabapentin causes intolerable side effects (81% response rate) 1, 2
• Both drugs significantly improve neuropathic pain and pruritus in hemodialysis patients with peripheral neuropathy 2

Opioid-Induced Pruritus

• Consider gabapentin as an alternative antipruritic agent when naltrexone (first-line) is contraindicated or ineffective 3
• Use only after attempting opioid cessation or dose reduction when feasible 3

Generalized Pruritus of Unknown Origin (GPUO)

• Gabapentin is a reasonable third-line option after antihistamines and SSRIs have failed 3
• Listed alongside paroxetine, fluvoxamine, mirtazapine, naltrexone, pregabalin, ondansetron, and aprepitant as consideration options (Strength D recommendation) 3

Neuropathic Pruritus

• Gabapentin 300 mg/day is effective for neuropathic itch conditions like notalgia paresthetica, with significant improvement in severe pruritus (VAS >5) within 4 weeks 4
• Particularly useful when pruritus is associated with paresthesia, pain, or EMG-proven peripheral neuropathy 4, 2

Post-Burn Pruritus

• Gabapentin demonstrates 95% reduction in itch severity compared to 52% with cetirizine, with faster onset of action (74% reduction by day 3 vs 32%) 5
• All patients reached itch-free status by day 28 with gabapentin versus only 15% with cetirizine alone 5
• No sedation side effects reported, unlike antihistamines 5

When NOT to Use Gabapentin

Hepatic/Cholestatic Pruritus (Critical Contraindication)

• Do NOT use gabapentin in hepatic pruritus - this is explicitly contraindicated by British Association of Dermatologists guidelines (Strength D recommendation) 3, 6
• A small trial failed to show benefit over placebo in cholestatic pruritus 3
• Use rifampicin (first-line), cholestyramine (second-line), sertraline (third-line), or naltrexone/nalmefene (fourth-line) instead 3, 6

Practical Dosing Algorithm

Starting dose:

• CKD/dialysis patients: 100 mg after each dialysis session or daily 1
• Non-renal pruritus: 300 mg daily 4

Titration:

• Increase gradually based on response and tolerability 3
• Maximum dose up to 600 mg daily in some contexts 3
• Monitor for side effects: 37% of patients experience adverse effects requiring dose adjustment or discontinuation 1

If intolerant:

• Switch to pregabalin 25 mg after dialysis or daily, as 81% of gabapentin-intolerant patients respond to pregabalin 1

Common Pitfalls to Avoid

• Never use gabapentin as first-line therapy - always try emollients, topical therapies, and antihistamines first for GPUO 3
• Do not use in hepatic pruritus despite its effectiveness in other pruritus types 3, 6
• Start at low doses to minimize side effects, particularly in elderly or renally impaired patients 1
• Warn patients about potential side effects before initiation, as 37% may experience adverse effects 1
• Consider pregabalin as alternative rather than abandoning this drug class entirely if gabapentin is poorly tolerated 1

Evidence Quality Considerations

The British Association of Dermatologists guidelines provide the framework, noting gabapentin has only Strength D (expert opinion) recommendations for most pruritus types except the explicit contraindication in hepatic pruritus 3. However, research evidence from uremic pruritus 1, 2, post-burn pruritus 5, and neuropathic pruritus 4 demonstrates consistent clinical benefit in real-world practice, supporting its use in these specific contexts when conventional therapies fail.