Withdrawal symptoms after gabapentin discontinuation

Design

Case presentation

A 53-year-old woman with a history of liver cirrhosis due to ethanol abuse, ascites, portal hypertension, esophageal varices, and other comorbidities, presented to the emergency department with coffee ground emesis and black tarry stools. She was on a complex oral medication regimen, including spironolactone, nadolol, lactulose, ursodiol, ferrous sulfate, omeprazole, gabapentin, citalopram, and trazodone, without any known drug allergies. Upon admission, her hemoglobin levels decreased over several hours, and her blood pressure and pulse reflected a possible hemodynamic instability with an elevated ethanol concentration indicating recent alcohol ingestion. An upper gastrointestinal endoscopy with band ligation was performed, and she was admitted to the ICU. During her stay, she developed restlessness, confusion, and disorientation, suggestive of alcohol withdrawal, despite normal ammonia levels. Lorazepam was administered according to the CIWA-Ar protocol, but her symptoms persisted, and hepatic encephalopathy treatment with lactulose and rifaximin was initiated. On the fifth day, gabapentin and trazodone were restarted, and her condition significantly improved by the next day, requiring no further lorazepam. She had no further withdrawal symptoms and was discharged in a stable condition on day seven.

Study Author Conclusions

Gabapentin dependence and withdrawal requiring an 18-month taper in a patient with alcohol use disorder: a case report

Design

Case presentation

A high-functioning 32-year-old female was successfully treated for Alcohol Use Disorder (AUD) using a combination of gabapentin 300 mg four times a day and psychosocial interventions. Concurrently, she was also on long-standing medications fluoxetine 20 mg daily for major depressive disorder and lisdexamfetamine 60 mg daily for ADHD, with no adjustments during her AUD treatment. After remaining in full remission from alcohol for twenty months on a total daily dose (TDD) of 1,200 mg of gabapentin, she experienced withdrawal symptoms such as sweats, nausea, increased tactile sensations, pain, numbness, and muscle spasms when she inadvertently missed a dose for a day. These symptoms recurred when her dose was reduced to 900 mg daily, indicating intolerance to tapering. Recognizing the patient's difficulty with tapering, her dose was increased to a total of 1,000 mg TDD, which she tolerated. The BRAVO Protocol, designed originally for opioid and benzodiazepine tapering, was chosen to guide the gabapentin taper, emphasizing a safe and compassionate approach to manage severe dependence and withdrawal. Gradually, she continued to reduce her gabapentin dose, although each reduction prompted withdrawal symptoms such as numbness, tremor, muscle spasms, and heightened anxiety. Initially, she tapered by 100 mg monthly until reaching 300 mg daily, then slowed the taper to 20-30 mg decrements monthly. For the last 100 mg, she reduced by as little as 5 mg every one to two weeks, eventually discontinuing its use at 60 mg TDD. The entire tapering process spanned eighteen months.

Study Author Conclusions

Design

Case presentation

A 58-year-old man was brought to the emergency department with acute respiratory failure and altered mental status, presenting a concerning clinical picture that started with a gradual decline in his responsiveness over three days. His medical history included chronic pain managed with an extensive regimen of opioid medications, including extended-release morphine and oxycodone/acetaminophen, as well as gabapentin. He also suffered from obstructive sleep apnea, chronic obstructive pulmonary disease, diabetes, and hypothyroidism. On the day of admission, he had taken an extra dose of morphine prior to his deterioration. Upon arrival at the emergency department, the patient was noted to have miotic pupils, suggesting opioid toxicity, and his oxygen saturation was critically low, improving somewhat with a non-rebreather mask. Despite administration of naloxone, he showed only partial improvement, highlighting a potential opioid overdose compounded by gabapentin use, which was later discontinued. Further examinations revealed acute respiratory acidosis, but brain imaging and cerebrospinal fluid analyses showed no acute pathology or infectious process. Despite a responsive initial improvement in respiratory function following supportive care, the patient remained encephalopathic, with intermittent fever spikes prompting broad-spectrum antibiotics and antiviral coverage. A ventilation-perfusion scan ruled out pulmonary embolism, and inflammatory markers remained unremarkable. Despite improvements in respiratory parameters, the patient's mental status did not show corresponding recovery, and he transferred from the ICU to a step-down unit while still encephalopathic. Subsequent days saw the emergence of flailing limb movements and agitated behavior resembling akathisia, necessitating physical restraints for safety, indicating a complex interplay of potentially drug-induced neurological effects and underlying central nervous system concerns. 

The psychiatrist, upon speaking with the patient's family, identified potential gabapentin withdrawal as a contributing factor to the patient's symptoms, given a history of similar symptoms when previously missing gabapentin. Due to the absence of an intravenous formulation and the patient's inability to swallow, a nasogastric tube was inserted for administration, with an initial dose of 300 mg gabapentin administered. This intervention quickly led to a reduction in the patient's abnormal motor activity, and a notable calming effect was observed. The gabapentin dosage was subsequently increased to 600 mg every 8 hours via a peg tube. Within 12 hours, nursing staff reported improved patient cooperation and the removal of restraints. By the following morning, the patient had a significant recovery, being oriented to time, place, and person.

Study Author Conclusions