RED – Do NOT prescribe
Gabapentin or pregabalin should not be prescribed if any of the following apply:
• Pain is not neuropathic in origin (e.g. chronic primary pain or other unexplained chronic pain conditions) or indication is low back pain (with or without sciatica).
• A previous course did not result in meaningful functional improvement.
• There is current or past substance use, evidence of diversion, or drug-seeking behaviour.
• To replace opioids or as a way of reducing opioid use.
• The potential harms are considered to outweigh the likely benefits.
ACTION: Do not initiate treatment. Document the decision and use alternative approaches.
AMBER – High risk
Caution is required when prescribing gabapentin or pregabalin in the following situations:
• Co-prescribing with opioids, benzodiazepines, Z-drugs, or CNS depressants due to an increased risk of sedation, respiratory depression and even death.
• Older people, due to increased susceptibility to sedation, confusion and falls.
• Respiratory disease (e.g. COPD, sleep apnoea) due to an increased risk of severe exacerbations and respiratory depression.
• Renal impairment, particularly moderate to severe chronic kidney disease due to reduced renal clearance leading to drug accumulation and increased risk of toxicity if doses are not adjusted.
• Mental health conditions, particularly depression or suicidal ideation, which may increase the risk of deterioration in mental health, self-harm or suicide.
ACTION: Avoid co-prescribing with opioids, benzodiazepines, Z-drugs, or other CNS depressants where possible. If prescribing in any of the above situations, ensure clear rationale, appropriate dosing, regular review, and risk-reduction measures.
GREEN – May be appropriate
Prescribing could be considered appropriate if all the following criteria are met:
• Pain has been assessed as neuropathic in nature and amitriptyline or duloxetine are ineffective, not tolerated, or unsuitable.
• Shared decision-making has taken place, and the person understands both the limited likelihood of benefit and the potential harms, including the risk of dependence at prescribed doses.
• Risk assessment has been completed, with no factors identified that would make gabapentinoid prescribing inappropriate.
• No concerns have been identified regarding dependence, misuse, diversion, sedation, respiratory depression, or co-prescribing with opioids, benzodiazepines, Z-drugs or other CNS depressants.
• Prescribing is intended as a trial, and functional goals have been agreed that will be used to determine whether treatment is continued or stopped.
• A plan for review and stopping has been made and discussed with the person.
ACTION: Prescribing may proceed as a trial with planned review.