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- David J Rowbotham (3 March 2006)
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Gabapentin interactions to avoid
- Michael I Carter (16 February 2006)
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David J Rowbotham, Author of article Leicester
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I am not aware of any suggestion that gabapentin is associated with clinically important respiratory depression. However, I agree entirely, and this point was made in the article, that if this drug is to be used extensively in the perioperative period, we must be alert to any unexpected interactions Conflict of Interest:None declared |
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Michael I Carter, Consultant Anaesthetist None
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Professor D.J. Rowbotham in his editorial on “Gabapentin: a new drug for post-operative pain?”, argues that gabapentin and possibly pregabalin may have a place in treatment of post-operative pain.1 I cannot disagree with him, but I mention some caveats in the light of deceased records audits that I have been doing in the last three years. There are significant interactions with the pathophysiological conditions of the patients that we look after, and the pharmaceutical agents that they receive pre-operatively and peri-operatively, especially those with analgesic, anaesthetic or sedative effects. Although opiate causes for respiratory depression are looked for, other interactions must not be neglected.2 I provide these two case reports, albeit anecdotal reports are of limited value.3 A 47 year old diabetic, alcoholic and smoker had had his second AKA 80 days earlier. He was readmitted a couple of days after discharge with bilateral pleural effusions, MRSA in his AKA wound, and poor pain control as well as his osteomyelitis, nephrotic syndrome, retinopathy and cardiomegaly. He was on 16 various medications which included amitriptyline, nitrazepam, fentanyl 75mcg patches, paracetamol, aspirin, gabapentin 600mg, oromorph 5mg and MST 20mg. On our MRSA ward his pain control was not sufficient so the Oromorph was increased to 15-20mg 2hrly, and ketamine 10mg t.d.s. was added. Five days later his nursing observations showed somnolence, and a further two days later he suffered a cardio-respiratory arrest. When I initially surveyed these notes, I thought the somnolence was mainly a ketamine opioid-sparing effect, but I was reminded of this patient when another deceased patient record was examined. A 74 yr old male with renal impairment, diabetes, weight gain and abdominal pain, came in under the physicians for COPD treatment with BiPAP. He suffered also from obstructive sleep apnoea. He was put on gabapentin for his abdominal pain, despite his pre-existing conditions. He died a couple of days after the addition of gabapentin from a rapid deterioration of his respiratory failure. The data sheet for gabapentin indicates cautions in patients with renal impairment, and diabetes. With both patients, there appear to have been significant interactions of physiology, current pathology and polypharmacy resulting in terminal decline into respiratory depression. When we begin to introduce gabapentin in our acute pain management, we must be watchful not to choose the wrong patients and drug combinations. 1. Gabapentin: a new drug for post-operative pain? British Journal of Anaesthesia 96 (2): 152-5 (2006) D J Rowbotham 2. Opiate toxicity in patients with renal failure. BMJ 332 (2006) 345 -6. B R Conway, D G Fogarty, W E Nelson, C C Doherty 3. Case reports of suspected adverse drug reactions – systematic literature survey of follow-up. BMJ 332 (2006) 335-8, Y K Loke, D Price, S Derry, J K Aronson Conflict of Interest:None declared |
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