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Titration of anticonvulsants

We recommend that gabapentin is trialled before pregabalin. Some neuropathic pain, such as trigeminal neuralgia, tends to respond better to carbamazepine.

Often women, older patients and some younger men tolerate lower doses than other patients.

We recommend that patients gradually increase their dose, not expecting to see a reduction in pain for four to six weeks. They should keep the dose steady when they find a dose that suits them. Any reduction in dose should be carried out slowly, as failure of analgesia and dysphorias can occur with rapid dose reductions.

Side effects may occur, and these may either limit the maximum dose or prevent the patient continuing with the drug. If this does happen, the drug should be stopped over a couple of weeks if possible.

Gabapentin dosing schedule, starting at 300mg

Week

Morning

Noon

Evening

Week 1

0

0

300mg

Week 2

300mg

0

300mg

Week 3

300mg

300mg

300mg

Week 4

300mg

300mg

600mg

Week 5

600mg

300mg

600mg

Week 6

600mg

600mg

600mg

Week 7

600mg

600mg

900mg

Week 8

900mg

600mg

900mg

Week 9

900mg

900mg

900mg

Week 10

900mg

900mg

1200mg

Week 11

1200mg

900mg

1200mg

Week 12

1200mg

1200mg

1200mg

Note: If there is no response at a dose of 600mg tds, please consider referral to the Pain Clinic.

If 300mg is poorly tolerated as a starting dose, gabapentin can be started at a much lower dose, and increased more gradually. We recommend the following dosing schedule in this case:

Gabapentin dosing schedule, starting at 100mg

Week

Morning

Noon

Evening

Week 1

0

0

100mg

Week 2

100mg

0

100mg

Week 3

100mg

100mg

100mg

Week 4

100mg

100mg

200mg

Week 5

200mg

100mg

200mg

Week 6

200mg

200mg

200mg

Week 7

200mg

200mg

300mg

Week 8

300mg

200mg

300mg

Week 9

300mg

300mg

300mg

Week 10

300mg

300mg

400mg

Week 11

400mg

300mg

400mg

Week 12

400mg

400mg

400mg

Week 13

400mg

400mg

500mg

Week 14

500mg

400mg

500mg

Week 15

500mg

500mg

500mg

Week 16

500mg

500mg

600mg

Week 17

600mg

500mg

600mg

Week 18

600mg

600mg

600mg

Week 19

600mg

600mg

700mg

Week 20

700mg

600mg

700mg

Week 21

700mg

700mg

700mg

Week 22

700mg

700mg

800mg

Week 23

800mg

700mg

800mg

Week 24

800mg

800mg

800mg

Note: If there is no response at a dose of 600mg tds, please consider referral to the Pain Clinic.

Pregabalin dosing schedule  NB TWICE DAILY

Week

Morning

Evening

Week 1

50mg

50mg

Week 2

75mg

75mg

Week 3

150mg

150mg

Week 4

300mg

300mg

Note: If there is no response at a dose of 75mg bd, please consider referral to the Pain Clinic.

Carbamazepine dosing schedule

Week

Morning

Noon

Evening

Week 1

100mg

100mg

100mg

Week 2

200mg

200mg

200mg

Week 3

300mg

300mg

300mg

Week 4

400mg

400mg

400mg

If the response to a single drug is poor, consider using combinations of drugs, particularly a combination of a tricyclic and an anticonvulsant.

 

 

 

 

 

 

 

 

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Pain Service Website, Gloucestershire Hospitals NHS Foundation Trust
Webmaster Dr J G de Courcy, Consultant in Pain Medicine and Anaesthesia
email: pain.webmaster[at]glos.nhs.uk

Page updated 19/02/2016