Perioperative Gabapentinoids

Kharasch, Evan D.; Clark, J. Kenji; Kheterpal, Sachin

doi:10.1097/aln.0000000000003394

Cited by 56 publications

(47 citation statements)

References 17 publications

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“…Moreover, the adverse events in this trial were not strictly related to dexmedetomidine dose, meaning that they are less predictable and that reducing the dose may not be a strategy for mitigation. This investigation exemplifies the critical need for carefully assessing the safety of multimodal regimens (and, in this case, opioid-free anesthesia), in addition to potential benefit, as has been called for previously in this journal [10][11][12] and by others. 13,14 Case in point, a four-drug intraoperative nonopioid regime added no benefit to standard anesthesia and did not appreciably change postoperative opioid use or pain scores despite the greatly increased complexity of the anesthetics.…”

mentioning

confidence: 67%

Opioid-free Anesthesia: Time to Regain Our Balance

Kharasch

Clark

2021

Anesthesiology

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F ashions come and fashions go. Changes in clothing, automobiles, and restaurants follow popular trends and are often periodic and cyclical. Ideally, medical change is driven not by fashion but instead by concepts of effectiveness and safety, and these concepts should improve and refine as better data become available. Trends hold true also in anesthesia practice, where for example intraoperative opioid selection has swung from long-duration to ultra-short duration and then at least partially back again. 1 Recent years have witnessed a new fashion in anesthesiology: "opioid-free anesthesia." For some, the opioid pendulum has swung clear past rational opioid use in balanced anesthesia to eliminating opioids intraoperatively and sometimes also postoperatively (opioid-free analgesia). Eradicating opioids from intraoperative and postoperative analgesic plans has been termed a "movement," 2 and like many "movements," it has attracted passionate proponents and spirited debate. 3,4 Nevertheless, clinical research and peer-reviewed evidence on the potential benefits and risks of opioid-free anesthesia have remained scant, needed, and called for. 5-7 This issue of Anesthesiology features two articles on opioid-free anesthesia that bring some light to the heat of the debate. The original investigation by Beloeil et al. 8 reports the results of a randomized clinical trial of balanced anesthesia with either remifentanil or dexmedetomidine (opioid-free). The review by Shanthanna et al. 9 provides a narrative exposition of opioid-free versus opioid-sparing approaches in the perioperative period. These articles are timely and important. The clinical trial 8 was investigator-initiated, multicenter, randomized, prospective, parallel-group, and single-blind, conducted in 10 centers in France, with an independent data and safety monitoring board to oversee the conduct and review safety data. Patients undergoing

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confidence: 67%

Opioid-free Anesthesia: Time to Regain Our Balance

Kharasch

Clark

2021

Anesthesiology

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“…Preemptive opioids should be especially avoided in opioid-naïve patients due to the risk of increasing postoperative pain perception and opioid use [180]. The use of perioperative gabapentinoids has been increasingly controversial owing to conflicting evidence of analgesic benefit and risks of adverse effects, including dizziness and synergistic sedation with concomitant opioids [61,[185][186][187][188][189][190]. The U.S. FDA has issued additional warnings regarding the risk of respiratory depression with gabapentinoids in patients who have respiratory risk factors, including the elderly, the renally impaired, those with chronic lung diseases, and those on concomitant sedatives [191].…”

Section: Preoperative Phasementioning

confidence: 99%

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

et al. 2021

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Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a “roadmap” for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.

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“…Gabapentin was first approved by the Food and Drug Administration in 1993 and it was initially meant to treat seizures, but as time goes by, it started to be used for chronic pain [30]. Gabapentin consists of a GABA molecule covalently bound to a lipophilic cyclohexane ring.…”

Section: Gabapentinmentioning

confidence: 99%

“…Considering its lipophilic profile, it can cross the blood-brain barrier and it can become an active GABA agonist. As an anticonvulsant drug, it can inhibit tonic hindlimb extension in the electroshock seizure model, as well as clonic seizures [30].…”

Section: Gabapentinmentioning

confidence: 99%

“…The pregabalin is an antiepileptic drug whose effectiveness to treat neuropathic pain was discovered in 1965 [37]. It was originally used in the 1990s as an anticonvulsant drug [20] and in 2004 it was approved by FDA for neuropathic pain, then fibromyalgia in 2007 and spinal cord injury neuropathic pain in 2012 [30]. Over the last decade, pregabalin has acquired a new use, for preventing postoperative acute pain and as an opioid spare strategy, and its use became widespread and routine in some countries [20].…”

Section: Pregabalinmentioning

confidence: 99%

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Gabapentinoids in Preventive Analgesia: Pharmacological and Clinical Aspects

Fernandes¹,

Henriques²,

Kasai³

et al. 2022

Topics in Regional Anesthesia

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Optimal postoperative pain management presents a challenge for healthcare providers across all surgical specialties, since it is estimated that many patients submitted to major surgeries do not receive an adequate analgesic treatment, increasing the risk of complications, length-of-stay and costs for health assistance. The development of new agents for postoperative pain control creates possibilities for better combinations in preventive and multimodal analgesia. Recently, the use of gabapentinoids (gabapentin and pregabalin) in the perioperative period has become more popular. Several clinical studies and meta-analyses reveal that perioperative gabapentinoids may evoke a significant opioid-sparing effect and probably decrease the postoperative pain score. Gabapentinoids may be a good strategy for preventive and multimodal analgesia in major surgeries, particularly pregabalin, considering its pharmacokinetics profile. Situations where there are limitations of regional anesthesia techniques or in cases where there is an intention to reduce the use of opioids or anti-inflammatory drugs at the trans-operatory period are certainly good opportunities for their use. However, gabapentinoids are associated with several adverse effects, including sedation, dizziness, and peripheral edema. Therefore, further studies are needed to evaluate the real cost-effectiveness of this approach. Additionally, specific attention should be paid to minor and ambulatory surgeries as well as for the elderly patients to which gabapentinoids are clearly not beneficial and potentially harmful.

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Perioperative Gabapentinoids

Abstract: Supplemental Digital Content is available in the text.

Cited by 56 publications

References 17 publications

Opioid-free Anesthesia: Time to Regain Our Balance

Opioid-free Anesthesia: Time to Regain Our Balance

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Gabapentinoids in Preventive Analgesia: Pharmacological and Clinical Aspects

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