A 25-year-old woman on GLP-1 (glucagon-like peptide-1) receptor agonist titration who has not taken prescribed gabapentin for wrist pain but reports improvement—what additional management should be recommended?

Management of Wrist Pain in a 25-Year-Old Woman on GLP-1 Therapy

Since the patient reports improvement in wrist pain despite not taking gabapentin, the most appropriate next step is to reassess the underlying cause of the pain and consider non-pharmacologic interventions or alternative analgesics rather than restarting gabapentin. 1

Immediate Assessment Priorities

Re-evaluate the Wrist Pain Etiology

• Obtain a focused history to determine if the pain is mechanical (repetitive strain, carpal tunnel syndrome), inflammatory (tendinitis, arthritis), or neuropathic in nature, as this will guide treatment selection 2
• Perform a physical examination specifically checking for Tinel's sign, Phalen's test, range of motion limitations, and point tenderness to differentiate between carpal tunnel syndrome, De Quervain's tenosynovitis, or other musculoskeletal causes 2
• Document the timeline of symptom improvement relative to GLP-1 initiation, as weight loss from GLP-1 therapy may reduce mechanical stress on joints and improve inflammatory conditions 1

Consider GLP-1-Related Factors

• Note that gabapentin is listed as a weight-promoting medication that can increase the risk of weight-related complications, so discontinuing it may actually complement the patient's GLP-1 therapy goals 1
• Recognize that the patient's weight loss from GLP-1 therapy (mean 6.1-17.4% in non-diabetic patients) may be contributing to the spontaneous improvement in wrist pain by reducing mechanical stress 3

Non-Pharmacologic Management Options

First-Line Conservative Measures

• Recommend wrist splinting, particularly at night for suspected carpal tunnel syndrome, as this provides mechanical support without medication side effects 2
• Prescribe physical therapy with specific exercises for wrist strengthening and ergonomic modifications to address repetitive strain injuries 2
• Advise activity modification including frequent breaks from repetitive tasks, proper keyboard positioning, and use of ergonomic equipment 2

Adjunctive Therapies

• Consider occupational therapy evaluation for custom splinting and workplace ergonomic assessment if the pain is work-related 2
• Apply ice therapy for 15-20 minutes several times daily if there is acute inflammation or swelling 2

Alternative Pharmacologic Options (If Needed)

Preferred Analgesics

• Prescribe NSAIDs (ibuprofen 400-600 mg three times daily or naproxen 500 mg twice daily) as first-line pharmacologic treatment for inflammatory or mechanical wrist pain, as these do not promote weight gain 1, 2
• Consider topical NSAIDs (diclofenac gel) applied to the wrist 2-4 times daily as an alternative with fewer systemic side effects 2
• Use acetaminophen 500-1000 mg every 6 hours as needed for mild-to-moderate pain without anti-inflammatory needs 2

When to Consider Gabapentin Reinitiation

• Restart gabapentin only if there is clear evidence of neuropathic pain (burning, tingling, electric shock sensations) that has not responded to conservative measures and NSAIDs 1, 2
• If gabapentin is restarted, counsel the patient that it may cause 1-5% weight gain, which could partially offset the benefits of GLP-1 therapy 1
• Monitor weight trajectory closely (unintentional weight gain >2 kg in a month or ≥7% increase from baseline) if gabapentin is resumed 1

GLP-1 Titration Considerations

Continue GLP-1 Therapy as Planned

• Proceed with the scheduled GLP-1 dose escalation according to the standard titration protocol, as there is no contraindication related to wrist pain 1, 4
• Monitor for gastrointestinal side effects (nausea, vomiting, diarrhea) during titration, which occur in 17-44% of patients but typically resolve within 4-8 weeks 4, 5
• Assess weight loss progress at each visit, as continued weight reduction may further improve the wrist pain 1, 3

Medication Interaction Awareness

• Note that gabapentin does not interact pharmacologically with GLP-1 receptor agonists, so if reinitiation becomes necessary, there are no drug-drug interaction concerns 1, 2
• Be aware that gabapentin's weight-promoting effect is a class effect that applies regardless of the underlying pain condition being treated 1

Follow-Up and Monitoring Plan

Short-Term Follow-Up (2-4 Weeks)

• Schedule a follow-up visit to reassess wrist pain severity using a validated pain scale (0-10 numeric rating) 2
• Evaluate the effectiveness of conservative measures and determine if pharmacologic intervention is needed 2
• Continue GLP-1 titration and monitor for adverse effects during this visit 4

Long-Term Management (3-6 Months)

• Track weight loss trajectory and correlate with wrist pain improvement to establish whether weight reduction is the primary therapeutic mechanism 1, 3
• Consider specialist referral (orthopedics or hand surgery) if pain persists despite 6-8 weeks of conservative management 2
• Reassess the need for any analgesic medications once the patient reaches maintenance GLP-1 dosing and weight stabilizes 1

Critical Pitfalls to Avoid

• Do not restart gabapentin reflexively without first confirming that the pain is neuropathic in nature and has not responded to conservative measures 1, 2
• Do not overlook the potential benefit of GLP-1-induced weight loss on mechanical wrist pain, as this may be the primary reason for improvement 1, 3
• Do not prescribe weight-promoting medications (including gabapentin, mirtazapine, or amitriptyline) without first exhausting weight-neutral alternatives in patients on GLP-1 therapy 1
• Do not delay GLP-1 titration due to unrelated musculoskeletal complaints, as the metabolic and cardiovascular benefits take precedence 1, 4