Gabapentin for Musculoskeletal Pain Management

Introduction to Gabapentin Use

The American Geriatrics Society recommends gabapentin as a first-line treatment for neuropathic pain conditions, including diabetic neuropathy and postherpetic neuralgia, with effective doses typically ranging between 900-3600 mg/day in divided doses 1
Gabapentin works by binding to calcium channels (α-δ subunits) in the brain and spinal cord, inhibiting the release of excitatory neurotransmitters involved in pain 2

For neuropathic pain, the American Geriatrics Society suggests starting with lower doses (100-200 mg/day) and gradual titration in older adults due to increased risk of side effects 1
The American Geriatrics Society does not recommend gabapentin as a first-line treatment for musculoskeletal pain, instead suggesting the use of antidepressants (particularly duloxetine and TCAs), topical analgesics, and NSAIDs for inflammatory components 1, 2, 3, 4

The American College of Physicians recommends NSAIDs and acetaminophen for inflammatory and non-inflammatory musculoskeletal pain 2, 4
The American Geriatrics Society suggests the use of topical analgesics (lidocaine, salicylate, capsaicin) for localized pain 1, 4
The American Geriatrics Society recommends serotonin-norepinephrine reuptake inhibitors (SNRIs), particularly duloxetine, for chronic musculoskeletal pain 1, 3
Tricyclic antidepressants (preferably secondary amines like nortriptyline or desipramine to minimize side effects) are recommended as second-line treatments 1, 5

The American Geriatrics Society recommends starting gabapentin at low doses (100-200 mg/day in older adults) and titrating slowly if used for pain with neuropathic components 1
Monitoring for effectiveness and discontinuing gabapentin if not providing adequate pain relief is recommended 1, 5

For fibromyalgia and chronic widespread pain with muscle involvement, the American Geriatrics Society supports trials of antidepressants (duloxetine and TCAs) and pregabalin rather than gabapentin 1, 3
The American Geriatrics Society does not recommend "muscle relaxants" (methocarbamol, carisoprodol, etc.) for chronic musculoskeletal pain due to limited evidence and potential adverse effects 1, 3