Resource pack 3: Reviewing gabapentinoid use

Treatment should be reviewed regularly to assess effectiveness, safety and adherence. Early review should assess pain, function and tolerability. Longer-term reviews should occur every six to twelve months.

On this page:

3.1 Rationale for review
3.2 Identifying people for review
3.3 Planning reviews
3.4 Review during the trial period
   3.4.1 Early treatment and stabilisation
   3.4.2 Evaluating outcomes of the trial
   3.4.3 Switching between gabapentin and pregabalin
3.5 Review of long-term use
3.6 Criteria for continuing or discontinuing gabapentinoid treatment
3.7 Documentation at review
3.8 System measures to support reviews
Appendix 3a: Patient information leaflet – Reviewing your gabapentin or pregabalin for pain
Appendix 3b: Patient medication questionnaire – Gabapentin or pregabalin
Appendix 3c: Medication review template – Gabapentin and pregabalin

3.1 Rationale for review

Early improvement during a gabapentinoid trial does not mean the treatment will remain helpful over time. With continued use, gabapentinoids can cause problems such as sedation, dizziness, falls, cognitive effects, respiratory depression, misuse, dependence and withdrawal. Regular review is needed to confirm that benefit is maintained and to identify emerging harm and to determine whether treatment remains appropriate. Where benefit is unclear or adverse effects increase, dose reduction or discontinuation should be considered. Non-pharmacological approaches should also be reviewed, as these may improve function and reduce reliance on long-term medication.

Supporting tools for review:

• Appendix 3a: Patient information leaflet – Reviewing your gabapentin or pregabalin for pain can be shared with the person to support understanding and engagement ahead of review.
• Appendix 3b: Patient medication questionnaire – Pregabalin or gabapentin can be completed by the person before each review appointment to capture their current experience, helping to structure a focused, person-centred review.
• Appendix 3c: Medication review template – Gabapentin and pregabalin can be used to guide and record the clinical review, ensuring all relevant safety and effectiveness aspects are considered.

Audit tools for prescribing reviews are provided in Resource pack 5 to support safe and appropriate prescribing practices. These include adaptable templates, letters and patient-facing messages to facilitate both routine medication reviews and targeted audits, such as those for people at higher risk or with renal impairment.

3.2 Identifying people for review

All people prescribed gabapentinoids should be reviewed at least annually; however, priority should be given to people at higher risk, including those listed below:

Higher priority for review
Higher-risk prescribing:
• High doses or rapid dose escalation
• Co-prescribing with opioids or other CNS depressants (e.g. benzodiazepines, Z-drugs)
• Older or frail people, or those at increased risk of falls
• Renal impairment or other relevant comorbidities
• History of substance use or alcohol dependence
Concerning prescribing patterns:
• Infrequent ordering despite being on repeat prescription
• Reports of lost medication or repeated urgent requests
• Long-term use without recent review
Unclear or off-label indications:
• Use for non-neuropathic pain
• Uncertain or undocumented original diagnosis  

3.3 Planning reviews

Practical approaches to reviews
Integrating reviews into routine processes
• Annual medication reviews.
• Hospital discharge medicine reconciliation.
• Opportunistic reviews during routine appointments.
Coding
• Use of consistent codes (e.g. Chronic Pain Review) to ensure follow-up.
• Documentation of review dates within the prescribing system.
• Recording agreed plans on prescription notes or repeat slips.
Setting expectations early
• Agree a review date at initiation or dose change.
• Ensure people understand that ongoing treatment depends on demonstrable improvement.
• Where possible avoid “cold calling” people for review by preparing them in advance.
• Advise pre-operative people that analgesics will be reviewed after surgery.

In people receiving palliative care, reviews should focus on functional benefit, safety and harms, and advice should be sought from specialist services where appropriate.

3.4 Review during the trial period

3.5 Review of long-term use

People established on a gabapentinoid should be reviewed regularly to check whether the benefits previously experienced are maintained and whether harms are emerging, and to decide if treatment should continue. Table 10 provides a suggested frequency for review.

Table 10. Suggested review frequency based on individual risk

Structured review: key elements
Preparation
• Provide the person with information beforehand to support shared decision making (use Appendix 3a: Patient Information Leaflet: Reviewing your gabapentin or pregabalin for pain).
Clinical assessment
• Assess whether the treatment is providing benefit against the agreed functional goals.
• Check the original reason for prescribing remains appropriate.
• Ask the person about problems they are experiencing (e.g. weight gain, sedation, cognitive or balance issues) and consider whether these may be related to long-term gabapentinoid use, as people may not recognise them as adverse effects.
• Review renal function and adjust dose if required.
• Assess risk of respiratory depression, particularly in people with respiratory disease (e.g. COPD, sleep apnoea) and in those prescribed opioids or other CNS depressants.
• Check for concurrent use of opioids or other sedative medicines, reduce doses and discontinue where appropriate.
• Check for patterns suggesting misuse or diversion.
• Consider wider concerns including polypharmacy.
Consideration of patient factors
• Explore expectations and what matters most to the person at this stage of treatment.
• Revisit the agreed functional goals and whether these are still relevant.
Consideration of changes where appropriate
• Where benefit is uncertain consider a planned trial dose reduction to assess ongoing need.
• Many people with stable symptoms can reduce their dose without worsening pain or function.
• Where appropriate, aim to trial dose reduction or stopping every 6–12 months.
Explore alternatives
• Discuss non-pharmacological approaches already in use and any additional support that may be helpful.
• Where switching between gabapentinoids is considered appropriate, guidance is available from the SPS: Switching between gabapentin and pregabalin for neuropathic pain.

3.6 Criteria for continuing or discontinuing treatment

A decision to continue or discontinue treatment should be based on thorough assessment of risks and benefits. Table 11 outlines the main criteria for decision making.

Table 11. Criteria for continuing or discontinuing treatment

3.7 Documentation at review

At each review, record:

• The current dose, response to treatment, adverse effects, goal-based assessment, and whether treatment is to continue or be reduced.
• The planned date for the next review.
• The agreed functional outcomes used to support the decision, including reasons for continuation or discontinuation (see Resource pack 4 for reducing treatment).

3.8 System measures to support reviews

Whole-practice approaches to support gabapentinoid deprescribing
Electronic support tools
• Prescribing decision prompts that highlight key safety considerations and risks, such as concurrent opioid, benzodiazepine, Z-drug or other CNS depressant use, renal impairment, or high doses.
• Alerts for overdue reviews, escalating doses or frequent early requests.
Repeat prescription management
• Shortened reauthorisation intervals (24–25 days) to reduce early ordering or excessive ordering.
• Removal of repeat items not requested for several months to prevent unintentional continuation or stockpiling.
• Safety messages on repeat slips reminding people of review requirements.
• Where possible use of digital platforms such as the NHS App to share similar prompts or reminders.
Team-based governance
• A nominated lead prescriber overseeing initiation, titration and complex reviews.
• Partner/senior sign-off for dose increases beyond agreed thresholds.
• Multidisciplinary team discussion of complex cases or people at higher risk.
• Communication with secondary care where prescribing recommendations raise safety concerns.
Locum and new-starter support
• A concise practice prescribing guide describing practice expectations for initiation, titration and review.
• Clear expectations on avoiding new initiations or escalations without review.