Management of Gabapentin in Patients Undergoing Surgery
Continue gabapentin through the perioperative period without holding it for surgery, administering it with a small sip of water (30-50 mL) even when NPO, as this minimal fluid volume does not increase aspiration risk and abrupt discontinuation poses significant seizure risk in patients with epilepsy. 1
Critical Safety Consideration: Seizure Risk
- Abrupt gabapentin withdrawal can precipitate status epilepticus, even in patients without prior seizure history, particularly at higher doses 2
- For patients taking gabapentin for seizure control, continuing therapy is essential to prevent breakthrough seizures perioperatively 3
- The FDA label indicates gabapentin is approved for adjunctive therapy in partial onset seizures, making continuation critical in epilepsy patients 3
Perioperative Administration Protocol
Preoperative Dosing
- Administer gabapentin 2 hours before surgery to achieve optimal pharmacodynamic effect at the time of incision 1
- The ERAS Society recommends gabapentinoids as pre-anesthetic medication for opioid-sparing effects 4, 1
- Gabapentin can be taken with 30-50 mL of water even when NPO without increasing aspiration risk 1
Dosing Considerations
- Limit to a single preoperative dose (rather than multiple perioperative doses) to minimize sedation, dizziness, and visual disturbances while maintaining opioid-sparing benefits 4
- Use the lowest effective dose to reduce adverse effects, with dose adjustment for elderly patients and those with renal dysfunction 4
- Typical preoperative doses range from 300-1200 mg, with evidence supporting efficacy at 900 mg or higher 4
Evidence for Perioperative Use
Benefits
- Single preoperative gabapentin doses (300-1200 mg) significantly reduce postoperative pain scores and morphine consumption in the first 24 hours 4, 5
- Effective for reducing acute postoperative pain with opioid-sparing effects 4
- May reduce chronic postoperative neuropathic pain when continued postoperatively (19.6% vs 41.3% in control) 4
Risks in Older Adults
- Perioperative gabapentin use in patients ≥65 years increases risk of delirium (RR 1.28; 3.4% vs 2.6%), new antipsychotic use (RR 1.17), and pneumonia (RR 1.11) 6
- Risk is particularly elevated in patients with high comorbidity burden (combined comorbidity index ≥4) or chronic kidney disease 6
- Common adverse effects include sedation, dizziness, peripheral edema, and gait disturbance 7
Specific Clinical Scenarios
For Neuropathic Pain Patients
- Continue chronic gabapentin therapy at the patient's established dose to maintain pain control and avoid withdrawal symptoms 4, 1
- Therapeutic doses for neuropathic pain typically range from 1800-3600 mg daily 7, 8
- Gabapentin provides substantial pain relief (≥50% reduction) in 32-38% of patients with postherpetic neuralgia or diabetic neuropathy 7
For Seizure Patients
- Never discontinue gabapentin abruptly in patients taking it for epilepsy, as this is the primary indication requiring continuation 3
- Gabapentin withdrawal can cause status epilepticus even after only 2 days without medication 2
Postoperative Management
- Systematic use of gabapentinoids preoperatively is not recommended as routine practice for all surgical patients 4
- Gabapentinoids should be reviewed and tapered postoperatively if no longer indicated 4
- For opioid-tolerant patients, gabapentin may be part of multimodal analgesia but should not replace comprehensive pain management 4
Key Caveats
- Renal dosing adjustment is mandatory in patients with compromised renal function, as gabapentin is almost exclusively eliminated by the kidneys 3
- In elderly patients (≥75 years), increased gabapentin exposure occurs due to age-related decline in renal function, requiring cautious dosing 3
- The risk-benefit ratio is less favorable in older adults with multiple comorbidities, where delirium risk may outweigh analgesic benefits 6
- Avoid benzodiazepines concurrently, as they potentiate sedative effects 4