What is the typical starting dose of gabapentin (Neurontin) for nerve pain management?

Gabapentin Starting Dose for Nerve Pain

Start gabapentin at 300 mg once daily at bedtime on day 1, increase to 300 mg twice daily on day 2, then 300 mg three times daily (900 mg/day total) on day 3. 1

Initial Titration Protocol

The FDA-approved dosing schedule provides the most straightforward approach:

• Day 1: 300 mg at bedtime 1
• Day 2: 300 mg twice daily (600 mg/day total) 1
• Day 3: 300 mg three times daily (900 mg/day total) 1

This rapid 3-day titration to 900 mg/day is supported by both the FDA label and multiple guideline societies including the National Comprehensive Cancer Network and Mayo Clinic. 2, 3, 1

Target Therapeutic Dose

After reaching 900 mg/day, continue titrating upward by 300 mg every 3-7 days until achieving adequate pain relief. 2, 3, 4

• Minimum effective dose: 1800 mg/day (600 mg three times daily) for most neuropathic pain conditions 2, 3, 4, 1
• Maximum dose: 3600 mg/day (1200 mg three times daily) may be needed for optimal pain relief 2, 3, 4, 1
• Typical effective range: 1800-3600 mg/day in three divided doses 2, 3, 5

The FDA label notes that while doses up to 3600 mg/day were studied, additional benefit above 1800 mg/day was not consistently demonstrated in clinical trials. 1 However, clinical practice guidelines acknowledge that some patients require the higher doses for adequate relief. 2, 3

Administration Schedule

Gabapentin must be given three times daily due to its saturable absorption pharmacokinetics—once or twice daily dosing is inadequate. 2, 3 The maximum interval between doses should not exceed 12 hours. 1

Special Population Adjustments

Elderly or Medically Frail Patients

Slow the titration schedule significantly:

• Start at 100-300 mg at bedtime 2, 3, 4
• Increase by 300 mg every 3-7 days (rather than daily) 3, 4
• This reduces fall risk from dizziness, which is particularly problematic in elderly patients 4

Renal Impairment

Mandatory dose reduction is required for creatinine clearance below 60 mL/min: 4, 1

• CrCl 30-59 mL/min: 400-1400 mg/day in two divided doses 1
• CrCl 15-29 mL/min: 200-700 mg/day as single daily dose 1
• CrCl <15 mL/min: 100-300 mg/day as single daily dose 1
• Hemodialysis patients: Maintenance dose based on CrCl plus supplemental dose after each 4-hour dialysis session 1

Timeline for Adequate Trial

Allow 3-8 weeks for titration plus 2 weeks at maximum tolerated dose before declaring treatment failure—a full therapeutic trial may require 2 months or more. 2, 3, 4 Efficacy develops gradually over several weeks, not immediately. 3, 4

Expected Outcomes

In postherpetic neuralgia and painful diabetic neuropathy, approximately 32-38% of patients achieve at least 50% pain reduction with gabapentin 1800-3600 mg/day, compared to 17-21% with placebo. 2, 5 This translates to a number needed to treat of approximately 5-7 patients. 5

Critical Pitfalls to Avoid

• Do not rush titration in elderly patients—this substantially increases fall risk from dizziness 4
• Do not use once or twice daily dosing—three times daily administration is essential due to saturable absorption 3
• Do not discontinue abruptly—taper gradually over at least 1 week to avoid withdrawal symptoms 3, 4
• Do not abandon treatment prematurely—allow the full 2-month trial period before declaring failure 4

Common Adverse Effects

Expect dizziness (19%), somnolence (14%), peripheral edema (7%), and gait disturbance (14%) with gabapentin. 2 These effects are typically mild to moderate and often transient, usually subsiding within approximately 10 days from initiation. 3, 6 Adverse event withdrawals occur in approximately 11% of patients versus 8% with placebo. 5