Does gabapentin cause sexual dysfunction in an adult in remission from alcohol use disorder being treated for anxiety and agitation?

Gabapentin and Sexual Side Effects

Gabapentin does not cause sexual dysfunction and may be specifically preferred when sexual side effects are a concern. Multiple clinical guidelines explicitly state that gabapentin does not cause sexual dysfunction, making it an advantageous alternative to SSRIs/SNRIs in patients where sexual function is important 1.

Guideline-Based Evidence

The most authoritative evidence comes from clinical practice guidelines published in the Annals of Oncology, which directly address gabapentin's sexual side effect profile:

• Gabapentin "does not cause sexual dysfunction" according to guidelines for managing menopausal symptoms, where it was studied extensively for hot flashes 1
• Gabapentin has "no absolute contraindications" and is well-tolerated for anxiety-related symptoms 1
• Gabapentin may be specifically considered "if sexual dysfunction is a problem" with other medications or develops during therapy with SSRIs/SNRIs 1

Context for Alcohol Use Disorder and Anxiety

For your specific clinical scenario—an adult in remission from alcohol use disorder being treated for anxiety and agitation—gabapentin is particularly appropriate:

• Gabapentin is listed as a relapse prevention medication for alcohol use disorder at doses of 600-1,800 mg/day, with no reported hepatotoxicity 1
• The mechanism involves modulating GABA activity, which addresses both anxiety/agitation and supports alcohol abstinence 1
• Common side effects are dizziness, unsteadiness, and drowsiness (affecting up to 20% of patients), which markedly improve after the first week and are largely resolved by week 4 1

Important Caveat: Contradictory Case Reports

While guidelines state gabapentin does not cause sexual dysfunction, isolated case reports suggest otherwise:

• Individual case reports describe dose-dependent sexual dysfunction including anorgasmia, loss of libido, and erectile dysfunction with gabapentin 2, 3, 4
• One case series reported sexual dysfunction in 41% of patients on pregabalin (a related gabapentinoid), occurring even at low doses (50-100 mg/day) 5
• A small case series found anorgasmia in 3 of 11 older patients (>50 years) newly initiated on gabapentin, suggesting higher incidence than the <1% reported in epilepsy trials 4

Clinical Recommendation

Despite isolated case reports, prioritize the guideline evidence that gabapentin does not cause sexual dysfunction 1. The guidelines are based on larger, controlled studies specifically examining this outcome, whereas case reports represent rare individual experiences that may have confounding factors.

For your patient with alcohol use disorder in remission and anxiety/agitation:

• Start gabapentin at 300 mg/day and titrate to 600-1,800 mg/day as needed for symptom control 1
• Monitor for dizziness and drowsiness in the first week, which typically resolve by week 4 1
• Specifically ask about sexual function at follow-up visits, as this is rarely volunteered by patients but is crucial for medication adherence 4
• If sexual dysfunction does emerge (unlikely based on guidelines), consider dose reduction first before switching medications, as case reports suggest dose-dependency 2, 4

Gabapentin offers the dual advantage of treating anxiety/agitation while supporting alcohol abstinence, without the sexual dysfunction commonly seen with SSRIs/SNRIs 1.