DrJEDtalks: Nerve pain meds, Gabapentin.

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In a previous video, we talked about the various causes

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of neuropathic pain.

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That is nerve pain. Here we’ll focus primarily on

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the medical treatments.

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So to review, in general, causes

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of nerve pain may be from the neural entrapments,

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the pinched nerve in the, the neck, the low back,

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or other places in the body versus the neuropathies,

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peripheral neuropathy, diabetic peripheral neuropathy.

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So what do we do about this?

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Well, the treatment of nerve pain can be very difficult.

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Nerve pain can be very resistant to standard medications

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to treat pain such as ibuprofen.

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Tylenol doesn’t really seem to do much.

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Even the narcotic pain medicines don’t treat

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nerve pain very well.

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So what are the standard treatments for nerve pain?

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The primary medical treatments for neuropathic pain

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that is nerve pain are the big three.

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So, uh, the most commonly used is gabapentin followed

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not in two distant second by Lyrica, also called pregabalin,

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and then Cymbalta.

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Those would be the big three medications that can be used

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to treat neuropathic pain, to treat nerve pain.

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Now a quick survey of the internet might indicate,

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you might see, oh, gabapentin, uh, one,

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it has all these side effects.

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Gabapentin wasn’t even invented for nerve pain.

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It was invented to treat seizures like, well,

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I don’t have seizures, doc,

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why are you giving me this medication?

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Well, it turns out that for many

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and many people, gabapentin worked pretty well

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to decrease the nerve pain.

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Um, I have seen one particular study that has suggested

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that maybe it doesn’t work that great,

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but anecdotally of the thousands of patients I’ve given it

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to, sure there are some patients it doesn’t work.

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But there are many and many patients it does work.

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So it’s worth a try

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for the most part is what I’m saying here.

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Uh, gabapentin. Now let’s speak about gabapentin dosing.

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There are many and many and many and many

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and many steps to dosing gabapentin.

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Uh, daily max dose for gabapentin would be 3,600 milligrams.

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I typically abide by the mantra of start low and go slow.

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So I oftentimes implement gabapentin

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with the 100 milligrams.

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The bottle may say take two, three times a day.

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I oftentimes advise patients to

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begin maybe taking just the bedtime dose at first

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because the most common side effect

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of gabapentin is sleepiness.

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It can make you very sleepy, uh, as the doses get higher.

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Sometimes people note cognitive side effects, meaning, uh,

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they say it word processing gets more difficult.

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Um, they just sometimes don’t feel

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as sharp as they would like to.

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So let’s begin low and then go slow.

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So those one hundreds may be eventually dosing up

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to 200 milligrams three times a day.

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I want to convey another point here,

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and that is there’s no magic to dosing

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Gabapentin. Okay?

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So, uh, imagine that your hand is on the knob

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of a stereo, okay?

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The volume of the stereo.

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If you want more volume, you just turn the volume up

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so you hear the music louder.

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Uh, if that’s too much, you turn it down.

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So within the dosing parameters

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of those 100 milligram tablets

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or capsules, uh, if it says take two, three times a day,

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if you find it sufficient

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that you take 200 milligrams at bedtime

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and maybe 100 milligrams in the morning time,

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and that’s fine, then that’s fine.

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You don’t have to take all those doses

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of gabapentin completely acceptable.

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So let’s say you’ve dosed up,

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you’ve titrated up your gabapentin dosing

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to include 200 milligrams three times a day.

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You might come back and talk it over to your doctor.

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If you’re my patient, you’re coming back

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and you’re talking over with me, at which case we might

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increase the dose to the 300 milligram capsules.

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We might just say 300 milligram capsules three times a day.

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Alternately, we might just say 300 milligram capsules,

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and the bottle will say, take two, three times a day.

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And now this follows the same mantra, meaning you don’t have

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to jump right to taking 600, 600, 600,

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maybe you take 300 in the morning, 300 in the middle

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of the day, and then you take 600 at bedtime.

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Completely acceptable.

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Uh, I have some patients that maybe take something like that

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and then 900 milligrams at bedtime

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also completely acceptable.

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So let’s say for example, you come back to your doctor

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after a month or so of trying that gabapentin dosing up

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to 600 milligrams three times a day.

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That would be a total dose of 1800 milligrams per day,

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which is a reasonable dose.

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By the time you’re taking 1800 milligrams a day,

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you might truly be decreasing

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that neuropathic pain that you’ve been experiencing.

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Let’s say for example, maybe it’s making a difference,

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but maybe not quite enough,

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you might titrate it up a little bit more,

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and that would be maybe the 900

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milligrams three times a day.

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I rarely go above that dose, uh, occasionally

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to 900 milligrams four times a day,

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or 1200 milligrams three times a day.

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And that would take you to the max dose,

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which would be 3,600 milligrams

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for the daily max dose for gabapentin.

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Let’s say for example, you get up there someplace 2,400

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milligrams a day or greater,

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and it’s just not working for you

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or you are having side effects.

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You say, Hey, doc,

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I just have trouble waking up in the morning,

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staying focused at work.

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I can’t do some of the cognitive tasks that I need to.

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Then your physician then has the information to put in the,

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in the chart note to get you Lyrica, uh, lyrica

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slash pregabalin.

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I term it oftentimes as gabapentin’s, new

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and improved cousin is supposed to be cleaner,

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have fewer side effects, maybe work better,

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and that’s not always the case. I have

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Had some patients that had titrated up, Lyrica,

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wasn’t working for them, went back to gabapentin,

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and gabapentin seemed to be the better medicine.

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So that’s a quick review of the medication dosing

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and the medication use to treat neuropathic pain.

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Now, there are many other specific treatments

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for neuropathic pain.

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However, those are very specific

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to ver very specific pathologies.

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If you have neuropathic pain, you begin with gabapentin,

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Lyrica, Cymbalta.

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If you continue to have neuropathic pain, you speak

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with your physician and see if there are other options

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that you can treat your neuropathic pain

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to help you live your life, less pain,

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improve your function, improve your mood,

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just improve your quality of life.

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So hopefully you find this helpful.

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Once again, continue to take care of yourselves and be well.