Resource pack 2: Initiating a gabapentinoid

Medicines for neuropathic pain are often of limited effectiveness and benefit only a small proportion of people. Decisions to prescribe should be based on shared decision making following thorough clinical assessment, risk evaluation and patient education.

On this page:

2.1 Identifying neuropathic pain
2.2 Exploring alternative treatment options before gabapentinoids
    2.2.1 Non-pharmacological approaches
    2.2.2 Social prescribing in chronic pain management
    2.2.3 Alternative pharmacological treatments
2.3 Shared decision making
2.4 Setting functional goals
2.5 Safety considerations before prescribing
    2.5.1 Pre-prescribing safety assessment
2.6 Choice of gabapentinoid
2.7 Gabapentinoid trial, dosing and titration
    2.7.1 Dose adjustment in renal impairment
2.8 Treatment management plan and documentation
Appendix 2a: GP waiting room poster - Living well with pain
Appendix 2b: Structured consultation when considering gabapentin or pregabalin
Appendix 2c: Patient information leaflet – Gabapentin or pregabalin for pain
Appendix 2d: Medicine initiation template – Gabapentin or pregabalin
Appendix 2e: Patient trial plan – Gabapentin or pregabalin
Appendix 2f: Treatment agreement plan – Gabapentin or pregabalin

2.1 Identifying neuropathic pain

When considering gabapentinoid treatment, prescribers should assess whether the person's pain is likely to be neuropathic in origin using a validated screening tool, such as the sLANSS. A score of 12 or higher suggests neuropathic pain. Assessment findings should be documented to provide a baseline for evaluating treatment response and informing future clinical decisions. 

2.2 Exploring alternative treatment options before gabapentinoids

Where a diagnosis of neuropathic pain is identified, consideration should first be given to non-pharmacological and pharmacological alternatives. Non-pharmacological approaches should be continued alongside any medication.

2.3 Shared decision making 

Gabapentinoid prescribing should always follow a shared decision-making process. Discussions should cover the potential benefits and limitations of the medicine, the known risks, alternative approaches and the person’s preferences and goals. Prescribers should also explore biopsychosocial factors that contribute to the person’s pain experience. The Living with Persistent Pain in Wales guidance may support broader discussions around self-management and functional goals where appropriate.³⁹

Discussions should also include a clear explanation that gabapentinoid treatment is initiated as a therapeutic trial, with response reviewed and treatment discontinued if meaningful benefit is not achieved.

Clear expectations should be established at the outset. Only a small proportion of people, approximately 1 in 9, experience meaningful pain relief.^40-42 Treatment should therefore be framed as aiming to improve function rather than eliminate pain. Complete pain relief is rarely achievable, and unrealistic expectations can contribute to inappropriate long‑term prescribing.

Appendix 2b: Structured consultation when considering gabapentinoids provides a framework to support these conversations. People should also be offered Appendix 2c: Patient information leaflet – Gabapentin or pregabalin for pain to support understanding of how the medicines work, their potential risks, and alternative options.

2.4 Setting functional goals

Before treatment begins, the prescriber and person should agree on realistic functional goals, that is, measurable improvements that focus on improving daily functioning rather than eliminating or reducing pain intensity alone. Goals may include enhanced mobility, better participation in daily activities, increased ability to work or improved social participation. These goals should form the basis of later reviews and decisions about continuation or discontinuation.

2.5 Safety considerations before prescribing

Gabapentinoids are associated with a range of risks that must be considered before initiation and throughout treatment. These include common adverse effects that may affect day-to-day functioning, as well as more serious harms such as respiratory depression, dependence and misuse. 

2.6 Choice of gabapentinoid

Gabapentin and pregabalin are structurally similar medicines acting through the alpha 2-delta subunit of voltage-gated calcium channels. Bioavailability of gabapentin decreases as the dose increases whereas pregabalin bioavailability is largely independent of dose, which explains the increased risk associated with high dose pregabalin use. 
There are no head-to-head trials directly comparing the efficacy of gabapentin and pregabalin. Evidence suggests similar effectiveness, based on comparable NNTs. Gabapentin is generally preferred because pregabalin is considered to have greater misuse potential, related to its faster onset of action and recognised euphoric effects. Both medicines carry risks of dependence, withdrawal and respiratory depression.

Misuse potential of pregabalin
Pregabalin is considered to have higher misuse potential, is frequently sought by people with substance use risk or alcohol dependence and has a recognised high street value. Prescribing should be avoided in these circumstances.

2.7 Gabapentinoid trial, dosing and titration

Initiate treatment as a therapeutic trial with agreed functional outcomes to assess response (e.g. ability to perform daily tasks, or engagement in physical activity), with a planned review date and an exit plan outlining how treatment will be reduced and stopped if no functional benefit is demonstrated.
In people receiving palliative care, specialist services may use a different titration schedule to reflect clinical complexity or symptom burden; where this occurs, the agreed plan should be clearly documented and include how functional benefit and harms will be reviewed after the trial period.

Gabapentinoid prescribing and titration 
•    Start at a low dose and titrate gradually. Although the British National Formulary (BNF) includes daily dose increases, weekly titration is preferred in primary care to reduce adverse effects, minimise harm and unnecessary dose escalation (see Tables 4 and 6 for dose titration examples).
•    Allow adequate time for a therapeutic trial:
         o    Gabapentin can take up to 8 weeks for dose titration, followed by 4 weeks at a stable dose.
         o    Pregabalin can take up to 4–6 weeks for dose titration, followed by 4 weeks at a stable dose.
•    Therapeutic effect is usually observed at doses of:
         o    Gabapentin ≥ 1,200 mg daily (in divided doses).
         o    Pregabalin ≥ 150 mg daily (in divided doses).^43,44
•    Maintain the lowest dose that demonstrates improvement in pain and function; there is no requirement to continue titration to the highest stated dose.
•    Higher doses (gabapentin above or equal to 600 mg three times daily or pregabalin above or equal to 150 mg twice daily) should only be considered following review and where some benefit has already been demonstrated.
•    Slower titration should be considered in older people, people with frailty, people known to be susceptible to adverse effects, and people with polypharmacy or renal impairment (see Tables 5 and 7 for adjusted titration examples).
•    If not tolerated or no therapeutic response is observed after 4–6 weeks at a stable dose, discontinue treatment gradually over a minimum of 1 week.⁸
•    Continue treatment only where benefit is demonstrated against agreed functional goals, using the lowest effective dose.

Adding a gabapentinoid to repeat medications
Do NOT add a gabapentinoid to repeat medications during initial trial.
If effective after trial period → add to repeat with clear review date.
If ineffective → taper dose, issue acute supply only.

Appendix 2c: Patient information leaflet – Gabapentin or pregabalin for pain and Appendix 2e: Patient trial plan help document treatment goals, dosing schedules, and review plans supporting a personalised and structured approach to care. 

2.8 Treatment management plan and documentation

Before issuing the first prescription, a clear treatment plan should also be agreed and documented with the person. Appendix 2f: Treatment agreement plan – Gabapentin or pregabalin can be used to establish shared understanding of the rationale for treatment, the potential benefits and limitations, and the expectations for review and monitoring.

Treatment plan requirements
The treatment plan should confirm that the person:
•    understands the expected benefit and limitations, including that benefit is seen in only a small proportion of people;
•    has been provided with a gabapentinoid patient information leaflet outlining the risks of addiction, dependence and withdrawal;
•    has been counselled on potential adverse effects and longer-term risks;
•    understands the importance of adherence to the agreed dosing regimen;
•    understands that medication forms one part of a broader pain management approach, alongside non-pharmacological strategies.
The treatment plan should document:
•    the indication and rationale for treatment;
•    relevant clinical findings and non-pharmacological treatments considered, including results from assessment tools, supporting the decision to prescribe;
•    details of the prescribed medicine, including choice of drug, planned dose titration schedule, intended trial duration, monitoring and review schedule;
•    the agreed functional treatment goals;
•    criteria for continuation or discontinuation, including stopping treatment where there is no meaningful benefit after an adequate trial, where adverse effects are significant, or where there are concerns about misuse, diversion or dependence.