Perioperative Gabapentinoids May Alleviate Pain, Reduce Opioid Use in Patients Undergoing Spine Surgery

Perioperative administration of gabapentin and pregabalin can alleviate pain and reduce reliance on opioids in patients undergoing spine surgery, according to the results of a systematic review published in the Journal of the American Medical Association.

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Spine surgery can cause pain in patients and successful pain management has been linked to better outcomes, shorter hospital stays, lower opioid consumption, and reduced costs. The use of gabapentinoids such as gabapentin and pregabalin can inhibit central nervous sensitization and treat neuropathic pain following spinal cord injury.

A previous analysis with no head-to-head comparisons and a limited sample size found that both gabapentin and pregabalin were effective in reducing postoperative pain and opioid consumption following spine surgery compared with placebo, but new trials with direct comparisons show conflicting results. The investigators aimed to compare the efficacy of the drugs through a systematic review and meta-analysis.

The primary outcome of the study was pain intensity, which was measured using the Visual Analog Scale (VAS). Secondary outcomes included adverse events (AEs) such as nausea, vomiting, dizziness, and opioid consumption.

A total of 485 studies were retrieved from a search of multiple databases. After the exclusion of duplicates and unrelated studies, 27 articles were ultimately included in the network meta-analysis. Across all the randomized control trials (RCTs), 1861 patients were included.

The VAS pain score outcome included 20 trials with 1427 patients. All different dosages of gabapentin and pregabalin have lower VAS scores than placebo, except for gabapentin 400 mg, 800 mg, and pregabalin 75 mg. Further, there was no significant difference between all various dosages of gabapentin and pregabalin.

Surface under the cumulative ranking curve (SUCRA) indicated that gabapentin 900 mg (SUCRA, 90.8%; mean difference, -2.67%; 95% CI, -3.80% to -1.54%) was most likely to be ranked the best.

In evaluating the opioid consumption outcome, 15 trials with 1070 patients were included. Head-to-head comparisons showed that all different dosages of gabapentin and pregabalin have lower opioid consumption than placebo, except for gabapentin 300 mg and 800 mg and pregabalin 75 mg.

Additionally, gabapentin 900 mg and 1200 mg led to lower opioid consumption than gabapentin 300 mg. SUCRA probability shows that gabapentin 900 mg (SUCRA, 91.0%; mean difference, -22.07%; 95% CI, -33.22% to -10.92%) was the most likely to be ranked the best by patients.

The nausea outcome included 20 trials with 1388 patients. There was no significant difference in nausea between all different dosages of gabapentin and pregabalin. SUCRA probability indicated that pregabalin 150 mg (SUCRA, 80.0%; odds ratio, 0.41; 95% CI, 0.17-0.98) was most likely to be ranked the best.

Prior studies have noted that although gabapentinoids have proven efficacy in managing pain, they are not recommended as the first line of treatment because of the substantial risk of important AEs. The investigators noted that a patient’s risk-benefit profile should always be evaluated before administration of gabapentinoids, but their study found no significant difference in the occurrence of AEs between different dosages of gabapentinoids.

The implications of the use of gabapentinoids can be far-reaching. Primarily, minimizing opioid use can improve patient outcomes, mitigate risks and complications, and contribute to efforts to address the opioid crisis, the study authors wrote.

Limitations of the study include the heterogeneity in methods and patient populations and the focus on short-term outcomes and the lack of analysis on long-term efficacy and safety data. Additionally, the researchers noted the limited generalizability of their findings to all patients undergoing spine surgery due to differences in surgical procedures and patient populations.

“It is crucial for future research to encompass larger, well-designed RCTs to validate our findings and ascertain the optimal dosage and long-term safety of these medications for patients undergoing spine surgery,” the study investigators concluded.

Reference

Tsai SHL, Hu C, El Sammak S, et al. Different gabapentin and pregabalin dosages for perioperative pain control in patients undergoing spine surgery: a systematic review and network meta-analysis. JAMA Netw Open. 2023;6(8):e2328121. doi:10.1001/jamanetworkopen.2023.28121