In this episode, I’ll discuss using gabapentin to reduce benzodiazepine use in patients hospitalized with alcohol withdrawal.
Because gabapentin’s mechanism of action fits the pathophysiology of alcohol withdrawal, many investigators have sought to test gabapentin for this condition.
Chronic ethanol use affects receptors in the brain in two ways:
1. Ethanol causes reduced sensitivity to the inhibitory neurotransmitter gamma-aminobutyric acid (GABA).
2. Ethanol inhibits the excitatory effects of glutamate at the N-methyl-D-aspartate (NMDA) receptor, resulting in additional NMDA receptors being produced.
When ethanol withdrawal occurs, the result is both a decreased ability to inhibit from reduced GABA sensitivity and an increased effect of glutamate from an increased number of NMDA receptors.
Gabapentin works independently of GABA receptors to inhibit the release of excitatory neurotransmitters such as glutamate. It is from this mechanism that gabapentin is thought to help normalize CNS tone in alcohol withdrawal.
A group of authors recently published in Pharmacotherapy a before-after retrospective cohort study to determine if their gabapentin taper-based protocol was benzodiazepine-sparing in patients experiencing alcohol withdrawal.
The study compared 100 patients before protocol implementation with 100 patients after protocol implementation. The authors included patients sequentially based on admission date, so the study should reflect a real-world continuous sample of patients.
The gabapentin taper used in the post-implementation group was: 900 mg every 8 hrs for 10 doses, followed by 600 mg every 8 hrs for 6 doses, then 300 mg every 8 hrs for 6 doses. If the patient had significant kidney dysfunction or risk of excessive sedation, a reduced dose was used.
The authors found that patients in the post-implementation group, on average, used about 10 mg of lorazepam equivalents during admission compared to about 23 mg of lorazepam equivalents in the pre-implementation group. This difference was statistically significant. Symptom progression, defined by average daily alcohol withdrawal assessment scale scores and length of stay, was similar in the before and after groups.
The authors concluded:
Utilization of a gabapentin taper resulted in significantly lower cumulative exposure to benzodiazepines and similar clinical outcomes in patients admitted for acute alcohol withdrawal.
Whether shifting exposure from benzodiazepines to gabapentin has any clinically meaningful impact on patient outcomes remains unknown.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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