Gabapentin
Aiya Almogaber, PharmD
Gabapentinoids, such as gabapentin and pregabalin, are commonly used in the management of epilepsy and neuropathic pain. However, these medications have recently come under scrutiny due to potential respiratory adverse effects, particularly in patients with COPD, which are characterized by progressive airflow limitation and recurrent exacerbations that impact a person’s quality of life.
In a study published in January 2024 in the Annals of Internal Medicine, researchers shined a light on the potential risks, such as severe exacerbations and respiratory failure, of gabapentinoids for patients with COPD. The study emerged following warnings issued by health authorities in North America and Europe regarding these serious respiratory complications.
“These warnings were based mainly on case reports, and there was a lack of large population-based studies on this topic, which led us to conduct this study assessing the association between gabapentinoid use and severe exacerbation of COPD [hospitalization],” said the study authors.
The findings offer valuable insights for pharmacists and other health care professionals and can equip them with critical data to inform their clinical decision making.
The study
By analyzing insurance records from the Régie de l’assurance maladie du Québec, Canada, Rahman and colleagues focused on a specific cohort: COPD patients aged 55 years and older who had been prescribed multiple respiratory medications between 1994 and 2015. Researchers compared those who started gabapentinoid therapy for conditions such as epilepsy, neuropathic pain, or chronic pain, with nonusers of gabapentinoids. Individuals were matched based on COPD duration, age, sex, and a nuanced time-conditional propensity score.
The primary outcome measured was severe COPD exacerbation requiring hospitalization, with secondary outcomes including moderate or severe exacerbation and respiratory failure.
The findings indicate that gabapentinoid use was associated with an increased risk of severe COPD exacerbation across all indications. Specifically, hazard ratios revealed a heightened risk ranging from 1.35 to 1.58, depending on the indication, with an overall hazard ratio of 1.39. The authors said that these findings largely aligned with their initial hypothesis, noting that they expected to identify an increased risk of severe exacerbations associated with gabapentinoid use. This underscores the importance of cautious gabapentinoid prescribing in this patient population.
The results are consistent with prior evidence from case reports, pharmacovigilance databases, and clinical studies highlighting the respiratory risks associated with gabapentinoids. Results were also consistent with existing warnings for cautious consideration when prescribing medications in this drug class.
Takeaways
Health care practitioners who are involved in managing patients diagnosed with COPD should thoroughly assess patients, take advantage of educational initiatives, and work collaboratively to effectively navigate the challenges associated with treating concurrent conditions in this vulnerable population.
As noted by the authors, these results highlight the importance of coordination among a patient’s circle of care, as the provider managing COPD may differ from the provider prescribing gabapentinoids.
Pharmacists are uniquely positioned to care for COPD patients, too, often serving as the final point of contact.
The first implication for pharmacy practice is clinical vigilance. When dispensing gabapentinoid drugs to patients with COPD, it is important to be mindful of the potential for severe respiratory exacerbations, among other potential adverse effects. Counseling and medication therapy management, areas in which pharmacists are adept, can help mitigate these risks.
Regular medication reviews offer an opportunity to assess the appropriateness of gabapentinoid use in patients with COPD. Pharmacists can collaborate with prescribers to consider or recommend alternative pain management strategies when necessary.
The decision to initiate or continue gabapentinoid therapy in COPD patients should involve a thorough risk–benefit analysis, taking into account the severity of pain or epilepsy and the patient’s overall respiratory status.
Patients should also be encouraged to independently monitor and report adverse drug reactions, including severe COPD exacerbations associated with gabapentinoid use. Symptoms may include an increase in the amount, thickness, or color of mucus or sputum; a noticeable change in shortness of breath; an increase in the severity of coughing; changes in the color or consistency of phlegm; new or worsening wheezing when breathing; chest tightness or discomfort; increased fatigue; difficulty sleeping due to breathing problems; or swelling in the ankles, feet, or legs.
Advise patients that recognizing and responding to these symptoms quickly can prevent further deterioration of their condition, aid in the accumulation of evidence that can guide future prescribing, and contribute to overall patient safety. ■