Gabapentin and Pregabalin
November 2019
Disclaimer
Does it matter?
Indications for use
Licensed indication Pregabalin Gabapentin
Generalized anxiety disorder Yes No
Peripheral and central neuropathic pain Yes No
Peripheral neuropathic pain Yes Yes
Adjunctive therapy for focal seizures
with or without secondary generalization
Yes Yes
Monotherapy for focal seizures with or
without secondary generalization
No Yes
Migraine prophylaxis No Unlicensed but BNF
contains dosing
information
Menopausal symptoms (in women with
breast cancer)
No Unlicensed but BNF
contains dosing
information
Fibromyalgia No No
Clinical practice
Moderate-quality evidence shows that oral pregabalin at doses of 300 mg or 600 mg daily has an important effect on pain in some people with moderate or severe neuropathic pain after shingles, or due to diabetes.
Low-quality evidence suggests that oral pregabalin is effective after trauma due to stroke or spinal cord injury. Pregabalin appears not to be effective in neuropathic pain associated with HIV. Very limited evidence is available for neuropathic back pain, neuropathic cancer pain, and some other forms of neuropathic pain.
Commonly prescribed for pain
Moderate-quality evidence that oral gabapentin at doses of 1200 mg daily or more has an important effect on pain in some people with moderate or severe neuropathic pain after shingles or due to diabetes.
Prescribing rates up: 2007-2012 : pregabalin up by by 350%, gabapentin up by 150%
10 x increase in gabapentinoid prescribing between 2000 and 2015 from 0.21% to 2.1 % of the population in UK prescribed these drugs
Many scripts off label
Cartagena F, Farias L, et al Prescribing Patterns in Dependence Forming Medications. Public Health Research Consortium 2017 http://phrc.lshtm.ac.uk/papers/PHRC_014_Final_Report.pdfhttps://www.cochrane.org/CD007076/SYMPT_pregabalin-chronic-neuropathic-pain-adultshttps://www.cochrane.org/CD007938/SYMPT_gabapentin-chronic-neuropathic-pain-adults
What’s happening?
Often co-prescribed with opioids
Concomitant treatment with gabapentin/pregabalin and opioids is associated with a significant increase in the risk of opioid-related death
This effect is more pronounced the higher the dose of gabapentinoid (1.8g gabapentin per day or more; 300mg pregabalin per day or more
Withdrawal - short term Irritability
AnxietyAgitationRestlessnessExcessive sweatingSensitivity to lightHeadacheConfusion or disorientationFeverHallucinationsRapid heart rate or heart palpitationsCatatonia or inability to moveStatus epilepticus
Why worry?
Gabapentinoids are associated with an increased risk of:
• suicidal behaviour,
• unintentional overdoses,
• head/body injuries, and
• road traffic incidents and offences.
• Pregabalin was associated with higher hazards of these outcomes than gabapentin
Participants aged 15-24 were the most vulnerable group
Associations between gabapentinoids and suicidal behaviour, unintentional overdoses, injuries, road traffic incidents, and violent crime: population based cohort study in Sweden
https://www.bmj.com/content/365/bmj.l4021
Why worry?
2 big meta analyses of gabapentinoid misuse suggest:
1.6% in the general community misuse Pregabalin / Gabapentin
3 - 68% of opioid misusers also misuse Pregabalin / Gabapentin, with patients with mental health/substance misuse issues being particularly at risk
Dependence: the need to continue taking a medicine to maintain a state of normality and avoid symptoms of withdrawal
Evidence of use for no medical purposes – (Estimates)
1.6% prevalence of gabapentinoid misuse in the general population and a
Prevalence from 3% to 68% among populations with opioid use disorder (PHE review)
Envoy KE, et al. Abuse and misuse of pregabalin and gabapentin. Drugs 2017; 77(4):403–26. https://www.ncbi.nlm.nih.gov/pubmed/28144823
CD regulations relate to the secure safe management and use of Controlled Drugs
• includes the whole journey of a CD from ordering / prescribing through delivery and storage through to administration / destruction
April 2019
1st April 2019 Pregabalin and gabapentin became Controlled Drugs
Schedule 3
words and figures
28 days
No emergency supply
No repeat dispensing by paper FP10 RD or electronic repeat dispensing (different to repeat prescribing)
September 2019
Dependence forming
medication prescribing
Prescribing trends
Numbers receiving long term scripts
Geographical differences
• Openprescribing.net
What should make me
concerned
Co-morbidities – respiratory, renal, elderly, frail suicidal behaviours, Substance misuse
Co-prescribing– especially opioids
Its not working
Rising doses risk increases
No clear indication
No clear timely review
Where else are they sourcing medication from? Private prescribing?
The third WHO Global Patient
Safety Challenge:Medication
Without Harm
Moments for Medication
safety
Primary health care facility consults
Referrals to another health care facility
or to another health care professional
Pharmacy visits
Admissions to a health care facility;
Transfers to another health care facility;
Discharges from a health care facility;
Treatment and care at home / nursing
home / hospice
What can we do
• Risks
• Polypharmacy
• Transitions
Raise a concern / report an incident
https://www.cdreporting.co.uk
CDAO contacts: https://www.cqc.org.uk/guidance-providers/controlled-drugs/controlled-drugs-accountable-officers
Questions?
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