ERAS PROTOCOL - Lyrica and Neurontin

[turnupthevapor]

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I think we can all agree gabapentinoids are opioid sparing (30%), I am putting together a protocol for the GYN dept and am contemplating only doing a single dose PreOP of Neurontin (3 cents a pill vs 7 dollars for lyrica). I am not seeing to much evidence to continue it past that point but wanted to poll the group. Question... Are you doing one dose of neurontin 300 or 600 or lyrica 75-150 and stopping or are you continuing it for a week or so and at what dose?

 

[vector2]

In residency we did lyrica 150mg day of surgery and then 150 qd for the duration of the stay. 75mg if old or renal insufficiency

 

[Shimmy8]

One dose of 300mg gabapentin if opioid naive and >65 (I think). 600mg if opioid tolerant or younger.

 

[dhb]

I think we can all agree gabapentinoids are opioid sparing (30%),

Can we?

 

[deleted875186]

Can we?

There are numerous studies on gabapentkn and pregabin showing reduction in postop pain scores and opioid use. I believe there are studies looking specifically at GYN surgeries as well. The doses are all over the place, so I have no idea. Hospital I’m at does one 300 gabapentin or one 75 lyrics on day of surgery only, predominantly for spine and ortho surgeries.

 

[Hoya11]

Can we?

I dont think they do anything either. As a pain doc the idea was that it took about a month to start working and that was at 3x per day, and only about 20% of the patients actually continued on it, all others felt too sleepy and not any benefit..

Not saying neurontin and lyrica dont have a place in chronic pain, they do, they help that small percentage, but in acute post surgical pain after one dose? Id honestly be curious to see the literature, and Im sure its the usual: underpowered, vague, biased, and based primarily on patient reported pain scores and opiate consumption in 24hrs which is subjective to patient/surgery/hospital and easy to manipulate..

these are more drugs that just obtund the surgical patient, like ketamine/mag, and what benefit is that? youve avoided opiates for something possibly dirtier

 

[Ronin786]

Can we?

Have yet to see any convincing literature that shows it's a meaningful reduction in opioid use. Especially with how much of an industry push there is for Lyrica/Neurontin.

Plus, having an obtunded patient in PACU will likely also limit their opioid consumption.

 

[fakin' the funk]

I think we can all agree gabapentinoids are opioid sparing (30%),

What's 30% less than zero?

 

[dhb]

What's 30% less than zero?

My point exactly.

 

[deleted697535]

What's 30% less than zero?

What are you doing instead? Tap catheters? epidural?

 

[fakin' the funk]

What are you doing instead? Tap catheters? epidural?

I was being a little facetious, since we have by no means defined what surgeries we're talking about beyond "GYN"

The vast majority of gyn I do is outpatient stuff. There are essentially no data on gabapentinoids and outpt opioid consumption.

Big GYN onc cases get epidurals, usually for 2 days. Usually no gabapentinoid as no narcotic needed anyway

 

[pain2b]

One dose of 300mg gabapentin if opioid naive and >65 (I think). 600mg if opioid tolerant or younger.

Do this and also add celecoxib if no CI. Ensure the gaba is given at night so that patient's drowsiness carries into the night. The drowsiness is a SE that you can use to your advantage.

 

[turnupthevapor]

I dont think they do anything either. As a pain doc the idea was that it took about a month to start working and that was at 3x per day, and only about 20% of the patients actually continued on it, all others felt too sleepy and not any benefit..

Not saying neurontin and lyrica dont have a place in chronic pain, they do, they help that small percentage, but in acute post surgical pain after one dose? Id honestly be curious to see the literature, and Im sure its the usual: underpowered, vague, biased, and based primarily on patient reported pain scores and opiate consumption in 24hrs which is subjective to patient/surgery/hospital and easy to manipulate..

these are more drugs that just obtund the surgical patient, like ketamine/mag, and what benefit is that? youve avoided opiates for something possibly dirtier

 

[Hoya11]

Those are exactly the silly studies that Im talking about.
I have seen firsthand, for many hundreds if not thousand of patients, without other confounders like other anesthetics and analgesics, the effects of lyrica and neurontin in pain clinic.
I dont believe them to be potent analgesics for acute pain, sorry.

Its just like people who give 50 of ketamine on induction and expect that to somehow alter the course of the patient hours and days later, its in the eye of the beholder

The idea of such a drug is wonderful, its new and its going to help save us from the opioid epidemic because im just so darn smart to use it.. im still waiting for that drug

 

[AKMD_1984]

Those are exactly the silly studies that Im talking about.
I have seen firsthand, for many hundreds if not thousand of patients, without other confounders like other anesthetics and analgesics, the effects of lyrica and neurontin in pain clinic.
I dont believe them to be potent analgesics for acute pain, sorry.

Its just like people who give 50 of ketamine on induction and expect that to somehow alter the course of the patient hours and days later, its in the eye of the beholder

The idea of such a drug is wonderful, its new and its going to help save us from the opioid epidemic because im just so darn smart to use it.. im still waiting for that drug

i agree with this and you echoed my sentiments. Also as a pain physician i constantly see 'we are using non narcotics to reduce the risk of addiction'. This statement fails to realize that addiction is very complicated phenomenon which rarely starts pre op in an otherwise low risk patient (high risk patients being having tendency for addictive behavior and deficits in impulse control). It is rarely diagnosed peri operatively by anesthesiologists. What labeling someone as a 'potential addict' does, is creates room for poor post op pain mgt which is the patient's right. One of the two true indications of opioids is in fact post surgical pain mgt and acute pain (other one being refractory malignant pain). Just because someone gets 0.5 mg of dialudid x 8 doses after their ex-lap, does not mean they will become addicted 2 weeks from now and fall a victim to 'opioid crisis' (another sensationalist term used routinely these days out of context).

Regarding gabapentin - it works primarily for chronic neuropathic pain syndromes, such as radicular pain and diabetic neuropathy. I dont see it working for any facial neuralgias. It has never worked for osteoarthritis or nociceptive pain in my experience (we had a physiatrist locally writing huge doses of neurontin for knee OA - many were already old and then started falling...he would then increase the dose after they broke their hips...it was as comedic as it was embarassing).

In pain management - less is more. Less medications means less side effects also. No one talks about fall risk with neuronal membrane stabilizers, or GI bleed with NSAIDs. I am all for multimodal analgesia, but common sense is important also.

 

[turnupthevapor]

i agree with this and you echoed my sentiments. Also as a pain physician i constantly see 'we are using non narcotics to reduce the risk of addiction'. This statement fails to realize that addiction is very complicated phenomenon which rarely starts pre op in an otherwise low risk patient (high risk patients being having tendency for addictive behavior and deficits in impulse control). It is rarely diagnosed peri operatively by anesthesiologists. What labeling someone as a 'potential addict' does, is creates room for poor post op pain mgt which is the patient's right. One of the two true indications of opioids is in fact post surgical pain mgt and acute pain (other one being refractory malignant pain). Just because someone gets 0.5 mg of dialudid x 8 doses after their ex-lap, does not mean they will become addicted 2 weeks from now and fall a victim to 'opioid crisis' (another sensationalist term used routinely these days out of context).

Regarding gabapentin - it works primarily for chronic neuropathic pain syndromes, such as radicular pain and diabetic neuropathy. I dont see it working for any facial neuralgias. It has never worked for osteoarthritis or nociceptive pain in my experience (we had a physiatrist locally writing huge doses of neurontin for knee OA - many were already old and then started falling...he would then increase the dose after they broke their hips...it was as comedic as it was embarassing).

In pain management - less is more. Less medications means less side effects also. No one talks about fall risk with neuronal membrane stabilizers, or GI bleed with NSAIDs. I am all for multimodal analgesia, but common sense is important also.

I would agree with you if 6% of patients who have minor surgery weren't becoming addicts.....on another note, Do you think one dose of 600 of neurontin will cause a lot of side effects? I have never had it to know how it feels but it does seem like a large dose. A lot of studies gave 1200 (not more effective) so i would imagine 600 is tolerated but 300 is also effective and has to be less sedating than 600..

 

[AKMD_1984]

I would agree with you if 6% of patients who have minor surgery weren't becoming addicts.....on another note, Do you think one dose of 600 of neurontin will cause a lot of side effects? I have never had it to know how it feels but it does seem like a large dose. A lot of studies gave 1200 (not more effective) so i would imagine 600 is tolerated but 300 is also effective and has to be less sedating than 600..

so are they becoming addicts BECAUSE of surgery or underlying impulse control issues and depression and propensity to be an addict? what about pre-existing opioid use?
what if they underwent this 'minor' surgery because they knew they could get a fix of iv opioids and were already addicted?
or how about they started becoming alcoholics after surgery. would you blame alcohol, or surgery or both?

the point is, these issues are inherently complex. to treat neurontin or lyrica or any wonder drug (ketamine comes to mind) as some sort of a miracle that will fix the opioid crisis is a farce.

secondly, so if it reduces opioid requirement - im all for that, but it does not prevent opioid use.

 

[deleted875186]

I agree, opioid use in the hospital postop is a meaningless outcome. It’s probably outpatient prescribing by surgical service and number of people still on opioids at hospital didcharge that really matters.

 

[Planktonmd]

These medications are simply sedatives and any sedative would produce the same "Opioid sparing" effect or even better.
So you can actually give a long acting Benzo (Diazepam, Lorazepam...) and get a better "Opoiod sparing effect for a fraction of the price!
But that would not be considered kosher from Eras point of view since big pharmaceutical companies will not make money which is the main goal of ERAS protocols.

 

[turnupthevapor]

so are they becoming addicts BECAUSE of surgery or underlying impulse control issues and depression and propensity to be an addict? what about pre-existing opioid use?
what if they underwent this 'minor' surgery because they knew they could get a fix of iv opioids and were already addicted?
or how about they started becoming alcoholics after surgery. would you blame alcohol, or surgery or both?

the point is, these issues are inherently complex. to treat neurontin or lyrica or any wonder drug (ketamine comes to mind) as some sort of a miracle that will fix the opioid crisis is a farce.

secondly, so if it reduces opioid requirement - im all for that, but it does not prevent opioid use.

Complex I agree. Just want to point out the 6% in the JAMA study was all opioid naive patients

 

[turnupthevapor]

These medications are simply sedatives and any sedative would produce the same "Opioid sparing" effect or even better.
So you can actually give a long acting Benzo (Diazepam, Lorazepam...) and get a better "Opoiod sparing effect for a fraction of the price!
But that would not be considered kosher from Eras point of view since big pharmaceutical companies will not make money which is the main goal of ERAS protocols.

Neurontin is 3 cents a pill and these drugs have antiallodynic, antihyperalgesic, antianxiety, as well as sedative effects

 

[epidural man]

I think we can all agree gabapentinoids are opioid sparing (30%), I am putting together a protocol for the GYN dept and am contemplating only doing a single dose PreOP of Neurontin (3 cents a pill vs 7 dollars for lyrica). I am not seeing to much evidence to continue it past that point but wanted to poll the group. Question... Are you doing one dose of neurontin 300 or 600 or lyrica 75-150 and stopping or are you continuing it for a week or so and at what dose?

Good question.

Lots of people are questioning the use of these drugs as a perioperative medication. But your question supposed that you are already going to give them, and that they work. I wish people would stick with the question asked, not answer a question that was never asked.

Anyway, we do both...some just preop, and some continue.

In my mind, I think lyrica would work better as a single dose. This is because clinically, I see an effect much quicker (when starting on a chronic pain patient) with Lyrica. However, I don't really know if that translates to an acute treatment because as some have pointed out - the mechanism of why acute treatment works may be completely different than why it works chronically.

 

[Planktonmd]

Neurontin is 3 cents a pill and these drugs have antiallodynic, antihyperalgesic, antianxiety, as well as sedative effects

These antiallodynic, antihyperalgesic effects in acute setting are debatable and likely a myth.
As for having anxiolytic and sedative effects ... also does Diazepam!