Gabapentin Titration from 100 mg Nightly
Starting from 100 mg nightly, increase to 300 mg at bedtime on day 4, then transition to 300 mg three times daily (900 mg/day) by day 7, and continue titrating upward by 300 mg every 3–7 days until reaching the minimum effective dose of 1800 mg/day (600 mg three times daily). 1, 2
Standard Titration Protocol
You must transition from once-daily to three-times-daily dosing within the first week because gabapentin has nonlinear, saturable absorption pharmacokinetics that make once-daily or twice-daily regimens ineffective. 1, 2 The interval between doses must not exceed 12 hours. 2
Week-by-Week Schedule
- Days 1–3: Continue 100 mg at bedtime (your current dose) 1
- Days 4–6: Increase to 300 mg at bedtime 1, 2
- Day 7: Split to 300 mg three times daily (900 mg/day total) 1, 2
- Days 10–14: Increase to 600 mg three times daily (1800 mg/day) 1, 2
- Days 17–21 (if needed): Increase to 900 mg three times daily (2700 mg/day) 1
- Days 24–28 (if needed): Increase to 1200 mg three times daily (3600 mg/day maximum) 1, 2
Target Therapeutic Dose
The minimum effective dose for neuropathic pain is 1800 mg/day (600 mg three times daily), and the maximum is 3600 mg/day (1200 mg three times daily). 1, 2 Moderate-quality evidence shows that 32–38% of patients achieve at least 50% pain reduction at doses of 1800–3600 mg/day, compared with 17–21% on placebo. 1, 3
Duration of Adequate Trial
Allow 3–8 weeks for titration plus an additional 2 weeks at the maximum tolerated dose before declaring treatment failure—an adequate trial requires roughly 2 months total because gabapentin's analgesic effect develops gradually over several weeks. 1, 4 Do not discontinue prematurely; efficacy may take the full trial period to manifest. 1
Renal Impairment Adjustments
Calculate creatinine clearance using the Cockcroft-Gault equation before initiating therapy because gabapentin is eliminated solely by renal excretion and requires mandatory dose reduction based on renal function. 1, 2
| Creatinine Clearance | Total Daily Dose | Dosing Frequency |
|---|---|---|
| ≥ 60 mL/min | 900–3600 mg | Three times daily |
| 30–59 mL/min | 400–1400 mg | Twice daily |
| 15–29 mL/min | 200–700 mg | Once daily |
| < 15 mL/min | 100–300 mg | Once daily |
For patients on hemodialysis, administer a supplemental post-dialysis dose of 125–350 mg after each 4-hour dialysis session. 2
Elderly Patient Considerations
If you are elderly or medically frail, use slower titration with 300 mg increments every 3–7 days or longer to minimize fall risk from dizziness. 1 Elderly patients experience higher adverse-event rates: dizziness (19%), somnolence (14%), peripheral edema (7%), and gait disturbance (9%). 1 The effective dose in older adults may be lower than the standard adult range of 1800–3600 mg/day. 1
Critical Pitfalls to Avoid
- Never use once-daily or twice-daily dosing for standard immediate-release gabapentin—three-times-daily administration is mandatory due to saturable absorption. 1, 2
- Do not rush titration in elderly patients; slower increments (every 3–7 days or longer) reduce dizziness-related falls. 1
- Do not declare treatment failure before completing the full 2-month trial at therapeutic doses, as efficacy develops gradually. 1
- Never discontinue abruptly—taper gradually over at least 1 week (longer if needed) to avoid withdrawal symptoms. 2
Common Adverse Effects
Expect dizziness (19%), somnolence (14%), peripheral edema (7%), and gait disturbance (9%) at therapeutic doses. 1, 3 These effects are typically mild to moderate and often transient, usually subsiding within approximately 10 days from initiation. 4, 5 Adverse event withdrawals occur in 11% of patients on gabapentin versus 8.2% on placebo. 3
Combination Therapy Options
Gabapentin can be used as a co-analgesic with opioids, tricyclic antidepressants (e.g., nortriptyline), or topical agents to enhance overall pain control. 1 Combining nortriptyline with gabapentin provides superior pain relief compared with either agent alone. 1