March 31, 2023
Medication optimization is a hot topic in post-acute and long-term care and a focus of AMDA’s very popular Drive to Deprescribe (D2D) initiative. Now practitioners have yet another opportunity to address their deprescribing challenges with a new quarterly D2D podcast. The first program addresses Optimizing the Use of Gabapentin and features Barbara Zarowitz, PharmD, NSW, BCPS, CGP, with Arif Nazir, MD, CMD, as host.
Dr. Nazir started the program by noting that he has seen an increase in publications documenting the growing use of anticonvulsants in older adults in general but more specifically in long-term care residents. This includes a significant increase in the use of gabapentin. In patients with dementia without a diagnosis of seizures, he said, almost 30% are using an anticonvulsant medication; this is increasing yearly.
“Surprisingly, when you look at approved indications for gabapentin and pregabalin, you find a small number of them,” said Dr. Zarowitz. For gabapentin, the indications are postherpetic neuralgia and as adjunctive therapy for partial-onset seizures. Pregabalin has slightly broader indications including managing fibromyalgia pain associated with spinal cord injury. “What we are seeing is off-label uses for both [gabapentin and pregabalin],” she noted. This includes their use of musculoskeletal pain, for which very little supporting evidence exists. “We also see it as part of multimodal analgesia regimens to reduce opioid use in perioperative pain, up to 30 days after the intervention,” she said. She suggested that it’s not unusual for long-term care facilities to see patients coming to them on these medications for this indication.
Dr. Zarowitz observed that there was an increase in the use of these drugs in people with Alzheimer’s disease and related dementia from 2015 to 2019, presumably to offset psychotropic use in patients who may have had behavioral manifestations that could not be managed non-pharmacologically and also to manage pain. Gabapentin and pregabalin have become a “bucketed form of therapy used extensively for various indications,” Dr. Zarowitz suggested.
This is concerning, she noted, as both drugs are on the Beers List of inappropriate medications for use in older adults. They can affect individuals cognitively and cause issues such as dizziness and blurred vision. Also problematic is that because these drugs aren’t labeled psychotropics, they may not be getting the heightened monitoring necessary to prevent or promptly address adverse events.
A challenge, suggested Dr. Zarowitz, is that we don’t have suitable substitutes for antipsychotics. “There really aren’t evidence-based alternatives. But we are in a bit of Catch-22 where we trade one class of medications for another, neither of which have adequate safety or advocacy data for the populations in which we see them used,” she said.
Dr. Zarowitz stressed that suitable behavioral interventions can be implemented and multimodal interventions are promising. These include using exercise with good nutrition, cognitive exercises, and caregiver training to manage behavioral symptoms. “We say it takes a village, and medication management is a collaborative effort if done correctly. This means incorporating individual skill sets of team members to enable a better care plan.” She noted that no single person can put together everything to create the perfect care plan and be accountable for implementing it.
Unfortunately, Dr. Zarowitz noted, there is no evidence-based algorithm or guideline for deprescribing this medication category. “We fall back on ‘let’s be intelligent in approaching this,’” she said. To a great degree, deprescribing these drugs will depend on how high a dose the person is on and how long they’ve been on the medication. Dose reduction should be accompanied by monitoring for withdrawal side effects that may include pain, anxiety, nausea, or the re-emergence of the issue that gabapentin or pregabalin was treating in the first place. “This may sound easy, but we know that it is very much an art and must be handled holistically and the patient must be monitored closely,” she said.
Dr. Zarowitz said she would like to see greater availability of pharmacists and behavioral health workers to help prescribers from beginning to end. She noted that the focus must be “what you measure and not what you hope to see.” This takes a trained, engaged team that works collaboratively on common goals.
Listen to this podcast in its entirety to hear more insights from Drs. Nazir and Zarowitz.
