Prolonged Gabapentin Use for Pain After Stroke Sparks Questions About Risks

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The latest here:

Prolonged Gabapentin Use for Pain After Stroke Sparks Questions About Risks

Key Takeaways

• Most older adults prescribed gabapentin after a stroke kept getting the drug for at least 1 year.
• Gabapentin is used off-label for post-stroke pain, despite limited guidelines and safety concerns.
• The researchers called for clear prescribing guidelines and more studies on long-term effectiveness.

Adults hospitalized for ischemic stroke who started gabapentin within 30 days of discharge often received a gabapentin prescription for at least a year, an analysis of Medicare claims showed.

Among 1,628 Medicare beneficiaries hospitalized for acute ischemic stroke, more than half -- 51.6% -- who were prescribed gabapentin had high and stable coverage for at least 1 year, according to researchers led by Lidia Moura, MD, PhD, MPH, of Massachusetts General Hospital in Boston. A threshold of 80% of days covered in a given period was used to determine high versus low coverage.

Overall, 42.5% had rapid low gabapentin coverage within 2 months of starting the drug, and 5.9% had gradually declining coverage over 8 months, Moura and co-authors reported in a paper posted to the medRxiv preprint server. The paper has not yet been peer-reviewed.

This study is the first to provide insights into real-world gabapentin treatment patterns among older Medicare stroke survivors, Moura and co-authors said.

"Notably, most older adults who were hospitalized for acute ischemic stroke and who initiated gabapentin within 30 days of discharge had gabapentin coverage for 12 months or longer," they wrote. "This highlights the need for clear prescription guidelines and more studies on the long-term safety and effectiveness of gabapentinoid use among older adults."

Gabapentin is approved for seizures and postherpetic neuralgia; gabapentin enacarbil is approved for restless leg syndrome. Despite limited indications, gabapentin is widely prescribed off-label.

The drug is used off-label to manage post-stroke pain but questions have emerged about its side effects and possible complications, particularly among older adults who often have multiple comorbidities and high rates of polypharmacy, Moura and colleagues noted.

Common effects of gabapentin include drowsiness, dizziness, blurry vision, and difficulty with coordination and concentration. In 2019, the FDA warned about serious breathing problems that may occur in patients using gabapentin who have respiratory risk factors. These factors included taking drugs that depress the central nervous system, conditions that reduce lung function, and older age.

Despite the risks older adults face, gabapentin prescribing among people ages 65 and up rose by 34% from 2016 to 2024, according to a CDC analysis.

While treatment duration varies based on patient response and tolerability, "animal studies have demonstrated motor function improvement with daily gabapentin treatment for 6 weeks post-stroke," Moura and co-authors observed. "However, there are no clear, universal guidelines for the use of gabapentin after acute ischemic stroke," they pointed out.

In addition, there is "weak and inconsistent literature on its proven effectiveness and post-initiation use for post-stroke pain, and treatment patterns remain poorly understood," they noted.

Moura and colleagues studied a 20% random sample of Medicare fee-for-service beneficiaries who were hospitalized for a first acute ischemic stroke between 2013 and 2021 and who started gabapentin in an outpatient setting within 30 days of discharge.

The researchers used a novel approach that combined a time-varying proportion of days covered (calculated every 2 months) with a latent class mixed model to identify patterns in the first 12 months after gabapentin was initiated, accounting for prescription overlap and hospitalizations.

The cohort had a mean age of 76 years. More than half of participants (59.7%) were female; 80.3% were white, 10.9% were Black, and 2.9% were Hispanic.

Most patients who stayed on gabapentin for 12 months did not have indications (such as seizures) or off-label indications (such as pain, insomnia, dementia, anxiety, or depression), the researchers said.

"Since gabapentin is widely used off-label, a lack of clear guidelines on optimal dosage and treatment duration may contribute to chronic prescribing," they wrote. "Treatment patterns in older adults are complex and influenced by several factors, including perceived efficacy, out-of-pocket cost, forgetfulness, drug interactions (given the high rates of polypharmacy), and side effects."

The analysis had limitations, Moura and co-authors acknowledged. The findings may not apply to younger people or those with Medicare Advantage. The study focused on outpatient treatment patterns and did not include patients discharged to skilled nursing facilities or inpatient rehabilitation. In addition, prescription records reflected gabapentin doses that were supplied, not actual consumption.