What’s the right dose of gabapentinoids, particularly when both doctor and patient want to reduce the use of opioids in large joint arthroplasty patients?
Gabapentinoids and Postop Respiratory Complications in TJA
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#totalkneearthroplasty#totalhiparthroplastySecondary#gabapentin#tetsuohnuma
To find an answer, a group of Duke University Medical Center researchers performed a study to shed light on this issue.
The study, “Dose-Dependent Association of Gabapentinoids with Pulmonary Complications After Total Hip and Knee Arthroplasties,” appears in the December 4, 2019 edition of The Journal of Bone and Joint Surgery.
Co-author Tetsu Ohnuma, M.D., M.P.H., a clinical researcher, epidemiologist, and data scientist in the Department of Anesthesiology at Duke University explained the background of the study to OTW, “The off-label use of gabapentin and pregabalin are commonly included in multimodal analgesics during surgical procedures, but it is reported the use of these medications was associated with an increased risk of postoperative respiratory depression.”
“Despite the widespread use of gabapentinoids, little is known about the optimal dose to balance pain control against the risk of adverse effects.”
“Of 858,306 patients who received primary total hip arthroplasty (THA) or total knee arthroplasty (TKA) treatments, 11.0% received gabapentin and 10.2% received pregabalin. Compared with no exposure to the drug being used by the particular group, all dose ranges of gabapentin and pregabalin were associated with greater odds of postoperative pulmonary complications (OR, 95% CI = 1.51, 1.40 to 1.63, for >1,050 mg of gabapentin and 1.81, 1.57 to 2.09, for >250 mg of pregabalin).”
“Exposure to gabapentinoids at any dose on the day of THA or TKA may increase postoperative pulmonary complications in a dose-response fashion, with minimal effects on perioperative opioid consumption.”
“These finding can help orthopedic surgeons when planning to prescribe gabapentinoids on the day of surgery as these drugs may have risks of respiratory complications after surgery.”
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This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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