Gabapentinoids
Sonya Collins
Nearly 5% of U.S. adults were prescribed a gabapentinoid in 2021, up from 4% of adults in 2015, a 17.5% increase in prescriptions over a 6-year period. While prescriptions are on the rise, these medications may be doing more harm than good for some of the older adults who receive prescriptions for them.
Common adverse effects of gabapentinoids include dizziness and impaired balance. Given that older adults are among the most frequent recipients of gabapentinoid prescriptions, it raises the question of whether the drugs increase their risk for falls and fractures.
According to a recent study published on November 13, 2024, in JAMA Network Open by Leung and colleagues, the answer is yes.
“There is a 30% increase in the odds of hip fracture within the first 60 days of being dispensed a gabapentinoid, and the association is more pronounced in patients who are frail and have chronic kidney disease,” said Miriam T.Y. Leung, MClinPharm, who is a PhD candidate at Monash University in Melbourne, Australia.
Gabapentinoids may not be safe for older adults
Researchers analyzed data on patients hospitalized for hip fracture with at least one prescription for a gabapentinoid before fracture in Victoria, Australia, between March 2013 and June 2018.
“Clinical trials are usually underpowered to detect hip fracture as an outcome,” Leung said. “For this reason, we analyzed real-world data to investigate a possible association between gabapentinoids and fractures.”
Nearly 60% of the patients in the study were over 80 years old, but fracture risk was similar across age groups. However, risk was highest among those with higher frailty scores and those with chronic kidney disease. Patients with high frailty scores were 75% more likely to fracture their hip than those with lower scores. Patients with chronic kidney disease had more than double the risk of hip fracture compared with those who did not have chronic kidney disease.
The study findings suggested that gabapentinoid use may increase risk of hip fracture to the same degree that other fall-increasing medications do.
“Gabapentinoids cross the blood-brain barrier and affect neurotransmitter release via multiple pathways. This has been associated with side effects that may precipitate falls, including dizziness and impaired balance,” Leung said. This can be a recipe for hip fracture in older adults with lower bone density who are already at risk of fracture.
Counseling patients and advising prescribers
Health-system pharmacists may advise physicians on the importance of considering each patient’s individual risk profile, including frailty status, renal function, and current use of other medications that raise the risk for falls, when deciding whether to prescribe a gabapentinoid.
As for safe dosing, Leung said, “Our study did not investigate whether dose was associated with hip fracture. However, the risk of hip fractures is highest at the start of treatment, so it’s advisable that patients start with a low dose and titrate slowly. This particularly applies to people who are frail or have renal impairment.”
The need to stay on gabapentinoids for neuropathic pain should be reviewed periodically, she said. When a decision has been made to stop the medication, “gradual discontinuation may be warranted.”
Community pharmacists may counsel older patients on the potential increased risk of falls and fractures when starting gabapentinoids and on how patients may reduce their risk (e.g, by avoiding alcohol while taking the medication). Patients should also consult their provider before they stop taking gabapentinoids. Tapering may be necessary to avoid withdrawal symptoms. ■