Clinical Question: Is the combinati...

Clinical Question: Is the combination of gabapentin (Neurontin) and morphine more effective for neuropathic pain than either unsalable article alone?

Setting: Outpatient (specialty)

studious mood Design: Crossover trial (randomized)

Allocation: Concealed

Synopsis: Gabapentin and morphine are widely used for neuropathic pain, still it is unclear whether the combination is better than either mix with drugs alone. The authors of this small close attention used a crossover design. Each patient took each mix with drugs or a combination of mix with drugss and served as his or her allow control. This study design makes it possible to identify statistically significant be the effects with a relatively small sample size. The 57 patients in the application of mind had diabetic neuropathy or postherpetic neuralgia that was at least moderate in severity and had been current for at least three month Those with postherpetic neuralgia were somewhat older than those with diabetic neuropathy (mean age: 68 versus 60 years). They stopped taking any medications for neuralgia and kept a pain diary for seven days to establish their baseline of the same height of symptoms.

Patients were then assigned randomly to common of four treatment sequences. Each succession included the following maximal target dosages for the four treatment regimens: (1) sustained-release morphine in a dosage of 60 mg twice daily, (2) gabapentin in a dosage of 3200 mg daily in three divided doses, (3) sustained-release morphine in a dosage of 30 mg twice daily plus gabapentin in a dosage of 800 mg three times daily, and (4) active placebo with a grave dose of lorazepam (Ativan; not believed to be effective for neuropathic pain, still patients were more likely to believe they were taking an active put drugs into because of its side effects) Each treatment period lasted five weeks, with the dosage slowly escalated during the first three weeks, results measured during the fourth week, and the physics tapered and stopped during the fifth week. Older and smaller patients had somewhat lower target dosages than the dosages listed above (60 mg for morphine alone and 2400 mg for gabapentin alone). chiefly patients did not reach the maximal dosage; the mean final dosages for morphine and gabapentin when used in combination were 35 mg and 1700 mg by day, respectively.

merely 41 of 57 patients complet the study; mostly of the others dropped revealed during the first treatment period. The primary issue was the mean pain intensity forward a scale from zero to 10 during the fourth week when patients were receiving the maximal dosage of each medicine Average pain intensity was 570 at baseline and was decreased to 450 with placebo, 415 with gabapentin, 370 with morphine, and 310 with the combination of gabapentin and morphine. The differences between the individual active physics and the combination were statistically significant further of marginal clinical significance. In general, upon a 10-point scale, a difference of les than 1 to 15 points is not clinically important. Patients receiving morphine alone or in combination with gabapentin had significant side effects; 21 percent receiving the combination had constipation, sedation, and thirsty mouth.

Bottom Line: The combination of gabapentin and morphine provides a small yet clinically unimportant benefit over either mix with drugs alone. Tricyclic antidepressants have been shown in other studies to be as effective as gabapentin and are plenteous less expensive, but were not studied in this trial. (Level of Evidence: 1b)

MARK EBELL, MD MS

research Reference: Gilron I, et al. Morphine, gabapentin, or their combination for neuropathic pain. N Engl J M March 31 2005;352:1324-34 Used with permission from Ebell M Gabapentin + morphine marginally better than either alone for neuralgia. Accessed online June 1 2005 at: http://www.InfoPOEMs.com.

COPYRIGHT 2005 American Academy of Family Physicians

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