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Gabapentin titration (upward)

OK, I posted earlier in the week to say my doctor had explained to me how to do this, but now I’m having doubts.

I’ve got 100mg tablets, and I need to get up to 300mg, three times a day (yes, that really would be nine tablets, but it’s only 'til I use up the ones I’ve got, and if all goes well with that, she’ll prescribe a higher dosage, so I don’t have to take as many,)

So, my recollection is that she said to take one the first day, two the second, three the third - which is exactly what my neuro told me. So far, so good.

But then she said to spend a week at three tablets a day, a week at six tablets a day, before finally up to nine.

However, jumping from three tablets a day to six is doubling the dose in one move! Could I instead just keep adding one tablet a day, as I have started, until I’m up to the full nine?

Tina

I don’t think its an exact science but my understanding from what you have said is to take an extra tablet a day up to 3 and then stay at 3 for a week. Then resume adding one a day until you get to 6, stay at 6 for a week and then add one a day until you get to 9

jane

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Hi Jane,

No, I’m pretty sure that isn’t what she said, and it isn’t the information I’m getting when I research it on the internet, either. It seems to suggest that once you’re up to three a day, it’s OK to go straight to six a day, with no intermediate stages. That’s why I’m questioning if it wouldn’t be easier - and just as safe - to keep incrementing by one tablet daily, until you get up to the desired amount. I regret, now, that I didn’t just ask her to prescribe the higher dose in anticipation.

She wants me to arrange a telephone consultation when I’m nearly out of them, but I’ve only got about 90 left. My maths isn’t too great tonight (couple of glasses of wine), but if I’m on three a day for a week (21), followed by six a day for a week (42), I won’t have enough left for a proper trial at nine. If I will be getting through them at that rate, the running out date is already in site, so I’d better book that telephone consultation now, before I even know how the trial has gone, as there might be a two-week wait for a slot.

I suppose I could pop into a pharmacy and ask them for clarification - although that won’t help with the problem that however I do it, I’m going to run out in no time, if I’m supposed to be building up to nine a day!

Tina

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Sorry, I mean sight - See what I mean about the wine?

Hi Tina

So the plan is to take 3 tablets a day for a week =21

Second weeks 6 tablets=42

Week three 9 tablets = 63

Total =126

Do you have that amount of tablets?

Hi,

No, I don’t! That’s what I mean about having to book the telephone consultation NOW. before I even know the outcome of the trial, because I’ll need more tablets regardless. Frankly, even if I (or we - the doctor and I) decide it’s not working, I’ll still need more tablets, to allow for weaning back off! Hence I realise this plan was not very smart, and I should have got her to prescribe more anyway. I don’t have enough to do it properly.

I did tell her how many I had left, and she didn’t spot the flaw in the plan either!

Tina

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Just checked my BNF Tina

300mg on day 1, Then 300mg twice daily on day 2, then 300mg 3 times daily (approx. Every 8 hours)on day 3, then increased according to response in steps of 300mg daily in three divided doses.

Does that ring any bells?

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Thanks for checking - but no, that confuses me even further (although perhaps it’s the wine). I think that may be the regime for epilepsy. 300mg three times daily should be what I end up on - not what I’m already on by Day 3. I’m only on 100mg tablets, so Day 3 (yesterday) was 3x100. I’m just wondering whether I should have been on 3x200 today, or at any rate, whether I can go ahead and take an extra 100 tonight. If an epileptic can be on 900 (total) by Day 3, then presumably it is well within the bounds of safety for me to take 400 today (Day 4)?

I think this is where the confusion arises: 100mg is a very small dose. The doctor told me the standard starting dose for epilepsy is three times as much! She thinks that’s why I got no benefit. So as long as I’m still feeling OK, presumably it’s safe for me to increase quite rapidly, as I’m still on less than an epileptic would be.

Tina

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When a neuro put me on Gabapentin …

  • He got the gP to prescribe it
  • He actually gave me a sheet of A4 with the steps on it:

1 on day one
2 on day two
3 on day three
4 on day four
5 on day five
6 on day six
And I stayed on 6 (2 X 300mg, 3 x daily) for a year.

This was for the “electric shock” type of pain. When I had some more constant pain im my legs, this was upped to 900mg 3x daily. Then I had to work up again, and was cautioned that if I ever had to come off Gaba, I was to taper off at a rate of 1 x300mg capsule each day.

Geoff

It is also the regime for neuropathic pain Tina

By day three, you would be on the 900mg a day.

The highest dose that can be taken is 1.8gms per day.

You can easily check this with a pharmacist. Like you say, you don’t have enough tablets anyway so need to contact your gp for a repeat.

Xx

BTW Tina, should you need to withdraw the dose after increasing, you would need to do taper off over at least a week.

Geoff,

That’s exactly what I’m minded to do (the 100mg more each day, that is), even though it’s not exactly as instructed.

To me, it seems much more controlled than going a week at 3x100, then suddenly doubling to 6x100,

I very much doubt anything will happen to me if I take two tonight (Day 4) instead of 1. It would already have been obvious if I were allergic to them (this is my second trial), and from what I can gather, the worst I might expect is feeling a bit sleepy or dizzy. If I’m going to bed anyway, that’s not going to matter much.

Interestingly, it sounds as if you were on 300mg right from the start, though. This is what I can’t work out - why I’ve been put on a tiny dose of just 1/3 the usual starting dose. I can only assume it’s because I was a bit reluctant to go on it at all, so he’s put me on the lowest possible dose. But I wasn’t warned it was so low I might not get any benefit.

If you were cleared to raise by 300 a day (I think that’s what you’re saying?), I’m sure I must be safe to raise by just 100 a day.

I don’t know of any reason I’m a “vulnerable patient”, and so would be placed on a lower dose than normal. I don’t think I have any renal problems, for example. So I think I have been piddling about with doses that were doomed never to work.

Tina

Going by Geoff’s list, he was on the full 1.8gms per day.

You would stop at Geoff’s day 3

Gawd, it’s doing my head in! Geoff’s Day 3 would, I think, be my Day 9 - i.e. if we each increased by 1 tablet a day, but he’s on 300mg, and I’m only on 100, those are the days on which our doses would be equivalent.

If Geoff has increased by 300 a day without dropping dead, or other serious adverse event, I’m sure I must be OK to increment by just 100. The only reason I can think of that I’m on such an unusually low dose was that I’m rather drug averse (not physically - in terms of willingness to take it, that is).

BUT, if I’m going to bite the bullet and take it at all, I may as well at least take a dose that works. What’s the point messing about with medication that’s too trivial to do anything? You get the worst of both worlds then - the nuisance of having to take them, and acceptance of any associated risks, without the chance of feeling better!

Yes, I did appreciate I’d need at least a week’s tapering from the higher doses (still not high compared to the max, which I think is 3600mg per day). Which is all the more reason I need to schedule a review with the doctor even before my experiment is complete, as I will need additional drugs, even if we decide I’m coming off.

This all sounded like such a brilliant idea, but now I’m thinking: “Why didn’t we just start again with a clean slate, and forget the neuro prescribed me just 1/3 of a proper dose?” I’m even wondering if he might have made a mistake, because he had clearly said “tablets”, and the pharmacy queried it, and said: “They only come in capsules at that dose.”

Now if he had really meant 300, they probably do come as tablets! Obviously, I’d rather be under-medicated than prescribed an overdose, but it all seems slightly odd.

Tina

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tina

both 100mg 200mg and 300mg come in capsule form.

i’ve never seen them in tablet form.

carole x

Why didn’t the silly neuro write the dose and regime down for goodness sake.

300mg a day, is the starting dose for the average patient with neuropathic pain Tina. You are on 100mg I take it because you are like me and dislike taking medication…yes?

What’s the point of taking small doses if they don’t work?

Contact your gp, get a proper prescription written up with the correct dosage and give the remainder of your 100mg tablets back to the chemist for disposal. Life with MS is confusing enough.

I promise you, if you want to take another 100mg tablet tonight you will be fine. Quite frankly, I will be amazed if it helps you in anyway though.

xx

The plot thickens, then, Carole. I’ve no idea why he said tablets, when they don’t come as that, and I’ve no idea why he’s put me on just 1/3 the usual starting dose, when I have no known contraindications. I’m really not surprised they didn’t work, and the GP said straight away: “It wasn’t a fair trial; it’s not enough!”

I can understand that the goal is always to be on the lowest dose that works, but it doesn’t sound as if 300mg a day ever had much chance of working. I may as well have taken a month’s worth of Smarties - and they would have been nicer.

Tina

xx

http://www.mims.co.uk/Drugs/central-nervous-system/epilepsy/gabapentin/

There you go Tina. I though this might explain the doses better

I am only assuming that’s the reason, Noreen.

When it was prescribed, it wasn’t made clear to me that it was a lower than normal dose, so I just expected everyone started at that. It’s not 'til you come on the forum and start asking, that you realise everyone else was prescribed more!

I’ve already taken the extra tablet. It’s a bit naughty to breach doctor’s instructions, but I NEVER do it without doing my research thoroughly, and having seen the standard doses, and the doses other people here are on, I’m confident, like you, that raising by 100mg will do no harm (and probably not any good either).

I have no known health issues that mean I shouldn’t have had the same starting dose as everybody else, so it can only be a nod to my reluctance. And the only reason for that was I’ve never been convinced it’s nerve pain. I will take drugs for symptoms I’m positive I’ve got, if they’re serious enough to cause distress. But I’m much more cautious about drugs for things I don’t think I’ve got. This pain doesn’t “feel” neuropathic to me, and furthermore it responds to conventional analgesics - albeit less well than it used to. So I was a bit wary of joining the conveyor-belt for neuropathic painkillers, when I’ve never been fully persuaded I have neuropathic pain - or not to a degree that bothers me.

I’d be more than happy to be proved wrong. In fact, I was only thinking today that if Gabapentin worked, and I could get rid of this foot pain, I might have a choice of shoes again, instead of only being able to wear one pair of walking boots. With things as they are, I honestly think I’d have to turn down an invitation to anywhere smart, because of the footwear problem. Even with dress-codes a lot less formal than they used to be, there are still places you can’t turn up in a pair of scuffed old walking boots, neither can you go to an interview in them, or be considered for any role (even voluntary) that requires smart attire.

Tina

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Thanks Noreen, but seems you have to register for that one.

However, I’ve checked several other (reputable) sources, many of them say slightly different (seems to depend on the brand, as Gabapentin comes under several brand names, as well as a generic drug), NONE say exactly what I was advised, and NONE say exactly what Geoff was advised, either.

But a common theme does seem to be an assumption that the basic starting point is 300, and the increments are 300 as well - in contrast with my tiny 100, which seems only to be for children or the elderly, or those with impaired renal function.

I think it’s lack of communication again. The neuro never said: “I’m starting you on a lower than normal dose, because I know you’ve had some reservations.”

Tina

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