Gabapentin as an Adjunct for Benzodiazepine Tapering
Gabapentin can and should be used as a pharmacological adjuvant to help mitigate withdrawal symptoms during benzodiazepine tapering, allowing for reduced benzodiazepine requirements and improved tolerability of the taper process. 1, 2
Evidence Supporting Gabapentin Use
The guideline evidence explicitly supports gabapentin as an adjunctive medication during benzodiazepine tapering:
- Gabapentin helps mitigate withdrawal symptoms that occur during benzodiazepine tapering, functioning as a pharmacological adjuvant to the reduction process. 1
- Recent retrospective data from 172 psychiatric inpatients showed that patients receiving gabapentin alongside benzodiazepines during withdrawal required significantly less total benzodiazepine dosing and had shorter hospital stays compared to those receiving benzodiazepines alone. 3
- A large healthcare system study of 4,364 patients demonstrated that gabapentin adjunctive treatment resulted in approximately 17.9% lower cumulative benzodiazepine dosages (median 2 mg vs. 4 mg lorazepam equivalent) compared to benzodiazepine-only treatment. 4
Recommended Gabapentin Dosing Protocol
When incorporating gabapentin into a benzodiazepine taper:
- Start with 100-300 mg at bedtime or 100-300 mg three times daily. 1, 2
- Increase gabapentin by 100-300 mg every 1-7 days as tolerated. 1, 2
- Titrate cautiously to avoid dose-dependent dizziness and sedation. 1
- Adjust dosing in patients with renal insufficiency, as gabapentin is renally excreted. 1
Integration with Benzodiazepine Tapering Schedule
The benzodiazepine taper itself should follow established protocols:
- Reduce benzodiazepines by 25% of the initial dose every 1-2 weeks for standard tapers. 1
- For patients on benzodiazepines for more than 1 year, extend the taper to 10% of the current dose per month rather than 10-25% every 1-2 weeks. 1
- Calculate reductions as a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions. 1, 2
- The taper rate must be determined by the patient's tolerance to withdrawal symptoms, not by a rigid schedule, and pauses are acceptable when withdrawal symptoms emerge. 1, 2
Critical Safety Warnings About Gabapentin Itself
A significant caveat when using gabapentin is that it carries its own withdrawal risk:
- Gabapentin itself can cause withdrawal symptoms upon discontinuation, particularly after chronic use at high doses. 5, 6
- Case reports demonstrate that gabapentin withdrawal can present with severe mental status changes, somatic symptoms, and hypertension even after a gradual week-long taper. 6
- When discontinuing gabapentin after the benzodiazepine taper is complete, taper the gabapentin slowly over weeks to months, similar to a benzodiazepine taper. 6
Monitoring Requirements During Combined Therapy
- Follow up at least monthly during the taper, with more frequent contact needed during difficult phases. 1
- Monitor for benzodiazepine withdrawal symptoms including anxiety, tremor, insomnia, sweating, tachycardia, headache, weakness, muscle aches, nausea, and confusion. 1
- Monitor for mood changes and suicidal ideation, and screen for depression, anxiety, and substance use disorders that may emerge during tapering. 1
- Watch for gabapentin-related side effects including dizziness and sedation. 1
Adjunctive Non-Pharmacological Strategies
- Cognitive-behavioral therapy (CBT) during the taper increases success rates and should be incorporated, particularly for patients struggling with discontinuation. 1, 2
- Patient education about benzodiazepine risks and benefits of tapering improves outcomes and engagement in the tapering process. 1
- Psychological support including mindfulness and relaxation techniques should be part of withdrawal management. 2
When to Refer to a Specialist
- Patients with a history of withdrawal seizures should be referred to a specialist rather than managed in primary care. 1
- Those with unstable psychiatric comorbidities require specialist involvement. 1
- Patients with co-occurring substance use disorders should be referred to a specialist. 1
- Cases where office-based tapering has been unsuccessful should be referred. 1