Should I taper gabapentin in a geriatric patient scheduled for total knee arthroplasty in 10 days who is currently taking 600 mg twice daily?

Preoperative Gabapentin Management in Geriatric Patients

Continue the current gabapentin 600 mg BID without tapering, as this is chronic therapy for an established indication that should be maintained through the perioperative period to prevent withdrawal and maintain baseline pain control.

Rationale for Continuation

The key distinction here is that this geriatric patient is already taking gabapentin 600 mg BID chronically (presumably for neuropathic pain or another established indication), rather than being considered for new perioperative gabapentin initiation. 1

• Chronic gabapentin therapy should be continued at the patient's established dose to maintain pain control and avoid withdrawal symptoms in patients with neuropathic pain. 1
• The American Pain Society advises that chronic pain medications, including gabapentin, should be continued on the morning of surgery and prescribed postoperatively to prevent withdrawal symptoms and maintain baseline pain control. 2
• Abrupt discontinuation of gabapentin can precipitate withdrawal symptoms, and the FDA label specifically states that "if the gabapentin dose is reduced, discontinued, or substituted with an alternative medication, this should be done gradually over a minimum of 1 week." 3

Why Tapering is Not Indicated

With only 10 days until surgery, there is insufficient time and no clinical benefit to tapering this chronic medication.

• The PROSPECT guidelines for total hip arthroplasty (applicable to total knee arthroplasty) concluded that "repeated doses of peri-operative gabapentinoids show evidence of pain reduction but are not recommended as routine medication due to clinically relevant side-effects" when used as new perioperative interventions. 4
• However, this recommendation applies to initiating gabapentinoids perioperatively, not to continuing established chronic therapy. 4
• The concern about gabapentinoid side-effects (dizziness, sedation, visual disturbances) in the perioperative setting relates primarily to new initiation or dose escalation, not to stable chronic dosing. 4, 1

Geriatric Considerations

The current dose of 600 mg BID (1200 mg/day total) is within the therapeutic range and appropriate for geriatric patients with normal renal function.

• The FDA label indicates that "care should be taken in dose selection" in elderly patients, with dose adjustment based on creatinine clearance values. 3
• For patients with creatinine clearance ≥60 mL/min, the total daily dose range is 900-3600 mg/day, making 1200 mg/day a conservative dose. 3
• Verify renal function before surgery, as elderly patients are more likely to have decreased renal function requiring dose adjustment. 3

Perioperative Management Plan

Administer gabapentin on the morning of surgery with a small sip of water, even during NPO status.

• Gabapentin can be taken with a small sip of water (typically 30-50 mL) even when NPO, as this minimal fluid volume does not increase aspiration risk. 1
• Continue the established dose (600 mg BID) throughout the perioperative period. 1
• Resume the usual dosing schedule postoperatively once oral intake is established. 2

Common Pitfalls to Avoid

• Do not discontinue chronic gabapentin abruptly in the perioperative period, as this risks withdrawal symptoms and loss of baseline pain control. 1, 2, 3
• Do not confuse chronic gabapentin continuation with new perioperative gabapentin initiation—the evidence against routine perioperative gabapentinoid use applies to new starts, not established therapy. 4, 1
• Do not assume the patient needs "optimization" by tapering—stable chronic dosing is already optimized for this patient's baseline condition. 1
• Avoid concurrent benzodiazepines if possible, as they potentiate gabapentin's sedative effects. 1

Postoperative Considerations

• Gabapentinoids should be reviewed and tapered postoperatively if no longer indicated for the original condition. 1
• For this patient with established chronic use, continue the home dose as part of multimodal postoperative analgesia. 1
• Monitor for adequate pain control and side effects (sedation, dizziness), adjusting only if clinically necessary. 4