What is the recommended dosing frequency of Gabapentin for a patient with end-stage renal disease (ESRD) and pruritus, once daily (qd) or twice daily (bid)?

Gabapentin Dosing Frequency for ESRD Pruritus

Gabapentin for uremic pruritus in ESRD patients should be dosed three times weekly (not daily or twice daily), administered after each hemodialysis session. 1

Recommended Dosing Regimen

The standard approach for gabapentin in hemodialysis patients with uremic pruritus is:

• 100-300 mg administered after each dialysis session, three times per week 1, 2, 3
• This is markedly lower than doses used in non-ESRD populations (which typically range from 900-3600 mg daily) 1, 4
• The most commonly effective starting dose is 100 mg three times weekly post-dialysis, which can be titrated up to 300 mg if needed 2, 3

Rationale for Post-Dialysis Dosing

Timing matters critically in ESRD patients:

• Gabapentin should be administered after hemodialysis sessions to avoid premature drug removal during dialysis 5
• This post-dialysis timing also facilitates adherence by linking medication administration to the dialysis schedule 5
• The FDA label confirms that for patients on hemodialysis, maintenance doses should be based on creatinine clearance with supplemental post-hemodialysis dosing after each 4-hour dialysis session 4

Evidence Quality and Efficacy

The British Association of Dermatologists guidelines (2018) provide the strongest recommendation:

• A multicenter, double-blind, placebo-controlled trial of 34 patients showed that 100 mg post-dialysis three times weekly produced visual analog scale reductions exceeding 50% compared to placebo 1
• Another study demonstrated 88.9% response rates with gabapentin versus 22.2% with placebo, with the lowest dose (100 mg three times weekly) being most frequently effective 2
• Gabapentin reduced pruritus severity from a median of 8/10 to 1/10 in 85% of treated patients 6

Critical Dosing Pitfalls to Avoid

Do not use daily or twice-daily dosing schedules in hemodialysis patients:

• The FDA label specifies that for creatinine clearance <15 mL/min (which includes dialysis patients), daily dosing ranges from 100-300 mg once daily for non-dialysis days, but dialysis patients require the post-hemodialysis supplemental dosing schedule 4
• Using daily dosing risks drug accumulation and increased side effects, as gabapentin is renally cleared 4
• Side effects (somnolence, dizziness, fatigue) occur in 26-47% of patients, making the lowest effective dose preferable 7, 3

Dose Titration Strategy

Start conservatively and titrate based on response:

• Week 1-2: Begin with 100 mg after each dialysis session (three times weekly) 2, 3
• Week 3-4: If inadequate response, increase to 200 mg three times weekly 1
• Week 5-8: Maximum dose of 300 mg three times weekly if needed 1, 2
• Assess efficacy at 3-8 weeks, as this is when maximal benefit typically occurs 3

Alternative Considerations

Gabapentin is superior to antihistamines for uremic pruritus:

• Cetirizine is specifically ineffective for uremic pruritus despite efficacy in other conditions 1, 5, 8
• Sedating antihistamines should be avoided long-term due to dementia risk, except in palliative care 1, 5, 8
• 63% of patients in one study had failed antihistamine therapy before gabapentin was initiated 6

For patients intolerant of gabapentin:

• Pregabalin 25 mg after dialysis may be substituted, with 81% response rates in gabapentin-intolerant patients 6
• Topical capsaicin 0.025% cream four times daily is an alternative, with marked relief in 82% of patients 8, 9