Treatment of Gabapentin Overdose
Gabapentin overdose is primarily managed with supportive care, as there is no specific antidote; hemodialysis can remove gabapentin effectively but is generally reserved for patients with severe toxicity combined with renal impairment. 1
Immediate Management: Supportive Care
The cornerstone of gabapentin overdose treatment is comprehensive supportive care, as no antidote exists 1. The FDA label documents that acute oral overdoses up to 49 grams have been reported, with patients experiencing:
All patients in reported cases recovered with supportive care alone 1. This emphasizes that most gabapentin overdoses, even at very high doses, have favorable outcomes without aggressive interventions.
Role of Hemodialysis
When to Consider Hemodialysis
The EXTRIP workgroup (2022) suggests AGAINST performing extracorporeal treatment (ECTR) in patients with normal kidney function 2. This represents the most recent high-quality systematic review on this topic.
However, hemodialysis may be indicated in specific circumstances:
- Patients with significant renal impairment AND coma requiring mechanical ventilation: The EXTRIP workgroup suggests performing ECTR in addition to standard care (weak recommendation, very low quality evidence) 2
- Patients with chronic renal failure who develop coma: Coma resolving with dialysis has been reported in this population 1
Hemodialysis Efficacy
When hemodialysis is performed, it effectively removes gabapentin 1, 2:
- High extracorporeal clearance (>150 mL/min) is achieved 2
- Elimination half-life is shortened to <5 hours with hemodialysis 2
- Gabapentin is assessed as "dialyzable" (quality of evidence grade A) in patients with decreased kidney function 2
Clinical Monitoring
Monitor for the following manifestations of toxicity:
- Neurological symptoms: Altered mental status, ataxia, drowsiness, lethargy 1, 3
- Respiratory status: Assess need for mechanical ventilation in severe cases 2
- Renal function: Critical for determining elimination capacity and need for dialysis 3
In dialysis patients, gabapentin elimination half-life increases dramatically to 132 hours (compared to 5-9 hours in normal renal function), making overdose more likely and prolonged 3.
Important Caveats
Mortality Risk
Gabapentin toxicity rarely results in death when taken alone 2, 4. A 2022 systematic review found that severe toxicity, mortality, and sequelae were rare in both patients receiving ECTR and those receiving standard care alone 2. However, one case report documented a death with postmortem gabapentin level of 88 μg/mL 5.
Co-ingestions
The risk profile changes significantly with co-ingestions, particularly:
- Opioids: Dangerous respiratory depression can occur when gabapentin is combined with opioids 6
- Benzodiazepines: Cumulative sedative effects increase risk 6
- Other CNS depressants: Additive effects on mental status and respiratory drive 6
Poison Control
Contact poison control (1-800-222-1222) for all overdose cases 1. This provides real-time expert guidance and contributes to surveillance data.
Special Populations
In patients with chronic kidney disease or those on dialysis: