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Uraemic Pruritus / Neuropathic Pain in CKD Pregnancy: Use with caution — limited human data; some registry data suggest possible increased congenital abnormality risk; specialist review required

Gabapentin (CKD Dosing)

Brand names: Neurontin

Adult dose

Dose: Neuropathic pain/uraemic pruritus in CKD: start 100 mg OD (eGFR 15-29) or 100-300 mg OD (eGFR 30-59). Normal renal function: 300 mg TDS up to 3600 mg/day.
Route: Oral
Frequency: Once to three times daily (frequency depends on eGFR)
Max: Normal renal: 3600 mg/day. eGFR 30-59: 1400 mg/day. eGFR 15-29: 700 mg/day. eGFR <15: 300 mg/day after each dialysis session.
Exclusively renally excreted — unchanged drug. In CKD, gabapentin accumulates causing sedation, myoclonus, encephalopathy, and respiratory depression. Start very low and titrate slowly. MHRA 2019: gabapentin is a Class C controlled drug — risk of misuse and overdose (especially with opioids).

Paediatric dose

Dose: 10 mg/kg
Route: Oral
Frequency: Three times daily
Max: 50 mg/kg/day (epilepsy); neuropathic pain: per specialist
Dose-reduce by eGFR in children with CKD. BNFc for age/eGFR-specific dosing. Not licensed for neuropathic pain under 18 years.

Dose adjustments

Renal

CRITICAL dose reduction in CKD — gabapentin is not metabolised, 100% renally excreted. Accumulation causes encephalopathy, myoclonus, respiratory depression, coma. eGFR 30-59: halve maximum daily dose. eGFR 15-29: reduce further to 700 mg/day. eGFR <15: 300 mg after each dialysis (dialysis removes gabapentin). MHRA 2017 warning specifically highlighted CKD as high-risk setting.

Hepatic

No dose adjustment required — not hepatically metabolised

Paediatric weight-based calculator

Dose-reduce by eGFR in children with CKD. BNFc for age/eGFR-specific dosing. Not licensed for neuropathic pain under 18 years.

Clinical pearls

  • MHRA 2019: gabapentin (and pregabalin) reclassified as Class C controlled drugs in UK due to misuse potential and overdose deaths, especially in combination with opioids. Prescribe with care in patients on opioid analgesia.
  • Uraemic pruritus: gabapentin 100-300 mg after dialysis is one of the most effective treatments. Nalbuphine ER and difelikefalin (kappa-opioid receptor agonist) are newer alternatives. Gabapentin remains first-line per NICE/ERA guidance.
  • Gabapentin toxicity in CKD: myoclonus is the key early sign — patients with CKD on unadjusted doses develop progressive encephalopathy, asterixis, and myoclonus. This can be mistaken for uraemic encephalopathy. Stopping or dose-reducing gabapentin resolves symptoms.
  • Dialysis removes gabapentin significantly (50-60% removed per 4-hour HD session). Supplemental post-dialysis dosing is required to maintain therapeutic levels in HD patients.
  • Peripheral oedema: gabapentin causes dose-related oedema via unknown mechanism. In anuric or oliguric dialysis patients, this can lead to significant interdialytic weight gain — monitor fluid status carefully.

Contraindications

  • Hypersensitivity to gabapentin

Side effects

  • Sedation/somnolence (dose-related — exacerbated in CKD by accumulation)
  • Dizziness
  • Ataxia
  • Peripheral oedema (can worsen fluid overload in dialysis patients)
  • Myoclonus/encephalopathy (gabapentin toxicity in CKD — often misattributed to uraemia)
  • Respiratory depression (especially with opioids)
  • Weight gain

Interactions

  • Opioids — synergistic CNS/respiratory depression; MHRA 2019 Class C scheduling driven partly by this interaction
  • Antacids (Al/Mg hydroxide) — reduce gabapentin absorption by 20%; separate by 2 hours
  • Morphine — increases gabapentin AUC 44%

Monitoring

  • Signs of gabapentin toxicity (sedation, myoclonus, encephalopathy)
  • eGFR and fluid status
  • Respiratory rate (if co-prescribed opioids)
  • Itch/neuropathic pain scores (efficacy)

Reference: BNFc; BNF 90; BNFc; MHRA DSU 2019 (Class C Controlled Drug); MHRA DSU 2017 (CKD Warning); ERA-EDTA Uraemic Pruritus Guidelines; SPC Neurontin. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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