From the Guidelines
I strongly recommend that you consult your healthcare provider immediately about your increasing nerve pain while tapering gabapentin, as they may need to adjust your current medications or add alternative treatments to manage your symptoms effectively. Your provider may consider slowing down the tapering schedule of gabapentin, as the return of your symptoms suggests that it was effectively controlling your nerve pain, and your nervous system may need more time to adjust to lower doses 1.
While duloxetine 60mg and meloxicam 15mg at bedtime can help with nerve pain and inflammation, they may not be sufficient as you reduce gabapentin. Your doctor might consider adding other medications like amitriptyline, nortriptyline, or pregabalin, which have shown efficacy in treating neuropathic pain 1.
Some key points to consider:
- Gabapentinoids, such as pregabalin, have been shown to be effective in treating neuropathic pain, with eight high-quality studies and seven medium-quality studies supporting its role in the treatment of pain in diabetic peripheral neuropathy (DPN) 1.
- SNRIs, such as duloxetine, have also been shown to be effective in treating neuropathic pain, with two high-quality studies and five medium-quality studies supporting its role in the treatment of pain in DPN 1.
- Non-medication approaches, such as physical therapy, TENS units, or topical treatments, may also be considered as part of a multimodal approach to managing nerve pain 1.
It is essential to work closely with your healthcare provider to find the best approach to managing your nerve pain, as abrupt discontinuation of gabapentin can cause withdrawal symptoms, including increased pain, anxiety, and insomnia 1.
From the FDA Drug Label
The most common adverse reactions associated with the use of gabapentin in adults, not seen at an equivalent frequency among placebo-treated patients, were dizziness, somnolence, and peripheral edema Approximately 7% of the 2074 patients >12 years of age and approximately 7% of the 449 pediatric patients 3 to 12 years of age who received gabapentin in premarketing clinical trials discontinued treatment because of an adverse reaction.
The patient's experience of nerve pain in both legs and feet returning as they taper off Gabapentin is consistent with the expected effects of discontinuing the medication. Gabapentin is used to treat nerve pain, and stopping the medication can lead to a return of symptoms.
- The Duloxetine 60 mg and Meloxicam 15 mg taken at bedtime are not directly relevant to the return of nerve pain when tapering off Gabapentin 2. It is likely that the patient's nerve pain is returning because the Gabapentin is being tapered off, and the patient may need to consider alternative treatments or adjustments to their current medication regimen to manage their nerve pain.
From the Research
Nerve Pain and Gabapentin Tapering
- The return of nerve pain in both legs and feet as Gabapentin is tapered off is consistent with the known effects of Gabapentin withdrawal 3, 4, 5.
- Studies have shown that Gabapentin can cause severe physiologic dependence and withdrawal, making tapering a significant clinical challenge 3.
- A case report highlighted the need for patient-centered slow tapers in patients with severe Gabapentin dependence and withdrawal, using the BRAVO Protocol as a framework for tapering 3.
Tapering Strategies
- The BRAVO Protocol, originally developed for opioids and adapted to benzodiazepines, provides a practical, patient-centered framework for tapering Gabapentin 3.
- A study suggested that slower tapering (over months or longer) of medications is associated with a lower relapse rate than quicker tapering (weeks) 6.
- Smaller dose reductions, especially at lower doses, made very gradually, may minimize the risk of withdrawal symptoms or relapse 6.
Concurrent Medications
- The patient is taking Duloxetine 60 mg and Meloxicam 15 mg, both at bedtime, which may interact with Gabapentin or affect the tapering process.
- A study compared the efficacy of Duloxetine, Gabapentin, and other medications on mechanical allodynia and neuroma pain, suggesting that combination therapy may be a therapeutic choice for neuropathic pain 7.