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Medicines for long-term pain

Gabapentin and This leaflet is about and pregabalin, two which are part of a group sometimes called gabapentinoids. The leaflet will give you some background about gabapentin and pregabalin and help you to understand how to use them in the way that’s best for you.

Before taking for long- What is ? term pain Neuropathic pain is a result of damage You should discuss with your doctor to the nervous system itself that results or other healthcare professional what in nerves sending out messages that you expect from treatment with pain are either incorrect or unhelpful. . Examples of neuropathic pain are the burning or tingling in the feet caused Pain-relieving (painkillers) are by diabetes, pain following shingles generally the first step in treating pain (post-herpetic neuralgia), or pain after surgery or an injury. However, it is following a pinched or trapped nerve. rarely possible to relieve long-term pain Words that people use to describe completely with painkillers. The aim of their neuropathic pain include: treatment is to reduce your pain enough to help you get on with your life. • tight; Medicines work best if you combine • shooting; them with other ways of managing • electric; symptoms, such as regular activity and exercise, and doing things that • tingling; you enjoy, such as work or study and • burning; social activities. Setting goals to help improve your life is an important way • piercing; to see if these drugs are helping. • freezing; or What are gabapentin and • stabbing. pregabalin? Gabapentin and pregabalin are Neuropathic pain is often compared used to treat neuropathic with ‘nociceptive’ pain, which is the (nerve) pain. pain more commonly due to tissue

2 damage and inflammation (such as Why am I being prescribed a a sprained ankle or broken bone, or gabapentinoid? after surgery). However, many painful Your doctor will prescribe a conditions, especially those that have gabapentinoid because they have gone on for some time, may have a decided you have some form of combination of neuropathic pain and neuropathic pain. nociceptive pain, and simple painkillers Doctors recommend gabapentin as well as medication for neuropathic and pregabalin as the drugs to try pain will be needed. first for neuropathic pain (except if There are different types of you have trigeminal neuralgia, in neuropathic pain, which can be which case they would recommend broadly categorised into peripheral a different ). You can find more neuropathic pain and central information and details of other drugs neuropathic pain. The peripheral that doctors would prescribe in the form arises from damage to the NICE guidance for neuropathic pain nerves which reach your organs and in adults. National and international extremities (hands and feet) and that experts repeatedly recommend, in a have pathways outside the spinal cord number of different guidelines, that and . These pathways may be gabapentin and pregabalin should very long (such as all the way to your be the first-choice drug when treating toes) or relatively short (for some of the neuropathic pain. nerves affecting your face and head). How do they work? Causes of peripheral neuropathic pain Gabapentin and pregabalin are used already mentioned include diabetes, to treat both neuropathic pain and infections and direct nerve damage, . Neuropathic pain can come but the list is long and includes the on with no warning or for no apparent effects of cancer and treatment reason. As with epileptic fits, nerve for cancer such as medication and pain can be unpredictable. These radiation therapy. two drugs are useful for neuropathic Central neuropathic pain comes from pain and epilepsy as they stabilise the damage to your brain or spinal cord nervous system in some way, and might be from, for example, a although the ways in which stroke or something causing abnormal gabapentinoids work are not fully pressure, or multiple sclerosis. understood.

3 Gabapentinoids are similar in tablets available, so that you do not structure to a substance called have to take several 300mg tablets at GABA (gamma amino butyric acid) once. that occurs naturally in our nervous Pregabalin is usually taken two or system. GABA is a . three times a day. Like gabapentin, are chemical it is increased from a lower dose up messengers that allow our nerves to to a dose that is effective. The usual communicate with one another. They starting dose is 75mg twice a day and are released to do their work by an this is increased as necessary over electrical nervous impulse activating a the next three to seven days. The ‘switch’ called a calcium . maximum daily dose of pregabalin is Gabapentinoids bind to calcium ion 600mg and it is available in a variety of channels, which probably contributes tablet sizes. to their effect on nerve transmission and reducing pain. They are also Many patients describe benefits thought to have more widespread from gabapentinoids fairly soon after effects. starting them, although for some people it will take a while to reach an How do I take them? effective dose. The full effects may also Gabapentin and pregabalin are take some weeks to develop. prescribed as tablets or capsules. If you are going to stop taking Gabapentin is usually taken three times gabapentinoids you should discuss this a day. It is started at a low dose and with your doctor who will advise you to gradually increased to the dose that is reduce your dose over a period of at effective. Some people may find they least a week. need quite a high dose to adequately reduce their pain. The usual starting When should I take it? dose is 300mg once a day on the first It is best to take gabapentin and day, 300mg twice a day on the second pregabalin regularly. You do not need day, and 300mg three times a day on to take them with food. If you are the third day. However, your doctor taking them twice a day, you should may adjust this to suit you. The daily take them 12 hours apart. If you are dose for most people is between 900 taking them three times a day, you and 3600 mg per day. If you need should take them eight hours apart. larger doses there are also larger-dose The timing is not critical, so if you

4 are an hour or two late in taking your your dose, often over a week. You medication, don’t worry. If you miss should not stop this sort of medication a dose, take the next dose at the abruptly. normal time – there is no need to take Gabapentin and pregabalin are anything extra for the missed dose. designed to be taken for long periods Gabapentin and pregabalin can of time. Many people have been sometimes make people drowsy or taking them successfully for years. If dizzy. If this happens to you, take care you have any further questions, the with what you plan to do. You should patient information leaflet which comes not operate machinery, drive a vehicle with the medication may be helpful, or be in charge of any situations where or your doctor or pharmacist will be this is important. Many people get able to give you advice and answer any used to these side effects, and after a queries. few weeks they are no longer an issue. Are there any side effects? Also, may increase the sedative Many of the side effects of gabapentin effects of gabapentinoids and this and pregabalin get less in time. The could make you more drowsy. list of side effects below is not a full If you have reduced function your list – see the patient information leaflet doctor will need to reduce the dose of for a complete list. Please remember both gabapentin and pregabalin. that many people take gabapentin and pregabalin without any side effects, or Antacids (for example, heartburn with mild effects which they put up with tablets) can reduce the amount of as they find the benefits outweigh any gabapentin that is absorbed from mild reactions. the stomach, so if you have taken a medication containing aluminium or Common side effects with both to reduce stomach acid it gabapentin and pregabalin are: is best not to take gabapentin until two • drowsiness; hours have passed. • dizziness; You should continue taking both gabapentin and pregabalin until • feeling tired; your doctor advises you not to. If you • mood changes; and are going to stop taking them, your doctor will give you a plan to reduce • swelling in the leg (oedema).

5 Some serious side effects which you should report immediately to your doctor are: • severe skin reactions (rashes); • allergic reactions (for example, rashes or swelling of the lips and tongue); • thoughts of harming or killing yourself; and • persistent abdominal pain (this may be due to an inflamed pancreas). Cases of abuse (taking too many) and dependence have been reported with gabapentinoids, although they are not common. Please talk to your doctor about this if you have a history of drug abuse Are there any alternatives? or dependence. Gabapentin and pregabalin may not Are there any reasons to avoid work for everyone. If you are not seeing gabapentinoids? any benefits after a few weeks, you People with reduced kidney should talk to your doctor about either function may not be able to take increasing the dose or stopping the gabapentinoids, or may need their medication. If you find the medication dose reduced. is giving you side effects, it may be worth trying a different gabapentinoid. You should see your doctor if you become pregnant, or are planning to There are alternative medications for become pregnant or breastfeed, as neuropathic pain or which can be taken gabapentin and pregabalin should not alongside gabapentinoids. These are normally be taken during pregnancy or and and, for while breastfeeding. trigeminal neuralgia, .

6 If your pain is severe or not responding Doctor’s viewpoint to drugs, you may need to be referred Over the last few decades, gabapentin to a specialised pain centre to try and pregabalin have changed the lives alternative medications and therapies. of many patients with neuropathic pain. For many people with longer-term These drugs can make troublesome pain, management strategies such and intrusive symptoms of nerve as physical therapy, or psychological damage totally manageable. However, therapies such as cognitive behavioural some people need some extra therapy (CBT), may also play a help with different combinations or significant role in helping people alternative medications. They key is to manage their symptoms and lead a treat each patient individually, and to fulfilling life. sometimes ask specialised pain clinics for help.

The author: Dr John Lee is a consultant in pain medicine who has been working in the field of pain management for the last 20 years. He has published widely in this field. The regulations controlling medicines change from time to time. For the latest information, please visit www.painconcern.org.uk, where you can also find out more about the evidence supporting this publication.

PAIN MEDICINES FOR LONG-TERM PAIN Leaflets in this series includeOpioids , Gabapentin and pregabalin and . You might also like our Managing your medications leaflet.

Gabapentin and pregabalin © John Lee. All rights reserved. October 2017. To be reviewed October 2020. This information is not intended to replace your doctor’s advice. We advise you to read the manufacturer’s information for patients, which your pharmacist will give you with your medication. Keep all medicines away from children.

7 Pain CONCERN www.painconcern.org.uk Pain Concern is a charity providing information and support to people with pain and those who care for them, whether family, friends or healthcare professionals.

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