What is the best course of action for a 65-year-old male patient with nerve damage in his left hand and feet, who has shown improvement with gabapentin, as indicated by his ability to close his left hand, and who is requesting an extension of this medication?

Management of Nerve Damage with Gabapentin Extension Request

Continue the gabapentin for this patient, as he is demonstrating clear functional improvement (ability to close his left hand), which represents a meaningful treatment response that justifies ongoing therapy. 1, 2

Immediate Clinical Actions

Verify Current Dosing and Optimize if Needed

• Confirm the patient is receiving an adequate therapeutic dose of 1800-3600 mg/day in divided doses (typically three times daily), as lower doses are often subtherapeutic for neuropathic pain 1, 2
• If the patient is on less than 1800 mg/day and tolerating the medication well, consider titration upward by 300 mg every 1-7 days to reach the therapeutic range 1
• The patient's functional improvement (hand closure) suggests gabapentin is working, but optimization may provide even better results 2

Assess Renal Function Before Extension

• Check serum creatinine and calculate creatinine clearance immediately, as gabapentin is renally excreted and this 65-year-old patient requires dose adjustment if renal impairment exists 3, 4
• Elderly patients are at higher risk for decreased renal function, making this assessment mandatory before continuing therapy 3, 4
• Dose adjustments are required for creatinine clearance <60 mL/min 3, 4

Evidence Supporting Continuation

Gabapentin Efficacy for Peripheral Neuropathy

• Gabapentin at 1200-3600 mg/day provides substantial pain relief (at least 50% reduction) in approximately 32-38% of patients with peripheral neuropathy, compared to only 17-21% with placebo (NNT 5.9-6.7) 2
• The American Academy of Neurology recommends gabapentin as a first-line treatment option for painful peripheral neuropathy with Level B evidence 5, 1, 3
• Gabapentin has demonstrated efficacy for both spontaneous pain and functional improvement in neuropathic conditions 6, 7

Patient's Functional Improvement is Clinically Significant

• The ability to close his left hand represents meaningful motor function recovery, which is a critical quality-of-life outcome that supersedes simple pain scores 6
• Functional improvements like this justify continuation even if pain relief is incomplete 2, 6

Critical Safety Monitoring During Continuation

Monitor for Common Adverse Effects

• Assess for dizziness (19% incidence), somnolence (14%), peripheral edema (7%), and gait disturbance (14%) at each visit, as these are the most common side effects 2
• Elderly patients are particularly susceptible to falls due to dizziness and ataxia, which increase in incidence with age 3, 4
• Ask specifically about balance problems and falls risk, as gabapentin can impair coordination 4, 2

Serious Safety Concerns to Address

• Do not abruptly discontinue gabapentin, as sudden cessation can cause withdrawal symptoms and potentially status epilepticus in susceptible patients 3, 4
• Screen for suicidal ideation at each visit, as gabapentin carries an FDA black box warning for increased suicidal thoughts and behaviors 4
• Watch for signs of serious allergic reactions including skin rash, fever, swollen glands, or yellowing of skin/eyes 4

Documentation and Follow-Up Plan

Establish Clear Treatment Goals

• Document the specific functional improvement (hand closure ability) as the primary outcome measure 6
• Set a follow-up appointment in 4-8 weeks to reassess both pain levels and functional status 1
• If the patient is not yet at therapeutic dosing (1800-3600 mg/day), continue titration and reassess after 2 weeks at maximum tolerated dose 1

Consider Alternative or Adjunctive Therapy if Response is Incomplete

• If gabapentin at 1800-3600 mg/day for an adequate trial (3-8 weeks titration plus 2 weeks at maximum dose) provides insufficient relief, switch to pregabalin or duloxetine rather than continuing to increase gabapentin 1
• Pregabalin 300-600 mg/day has stronger evidence (Level A) with NNT of 4.04 at 600 mg/day 5, 1
• Duloxetine 60-120 mg/day has NNT of 4.9-5.2 and is particularly effective for diabetic neuropathy if that is the underlying cause 5, 1

Address Underlying Etiology

• Obtain records from the hospital where nerve damage was diagnosed and treated to understand the specific etiology (traumatic, compressive, metabolic, toxic, etc.) 5
• If diabetic neuropathy, ensure HbA1c is optimized to 6-7% as glycemic control is the only disease-modifying intervention 5
• Consider physical therapy and occupational therapy referrals for functional rehabilitation, as these improve outcomes in neuropathic conditions with motor involvement 5

Common Pitfalls to Avoid

• Do not deny the refill based solely on lack of complete pain resolution, as functional improvement is equally important and this patient has demonstrated meaningful benefit 2, 6
• Do not use inadequate doses (many patients are prescribed 300-900 mg/day, which is below the therapeutic range of 1800-3600 mg/day) 1, 2
• Do not ignore renal function in this 65-year-old patient, as failure to adjust for renal impairment increases toxicity risk substantially 3, 4
• Do not combine with alcohol or other CNS depressants without careful counseling about increased sedation and fall risk 4