Gabapentinoids Linked to Respiratory Problems in Certain Patients

from Physician's First Watch 23.12.2019

Gabapentinoids Linked to Respiratory Problems in Certain Patients

By Kelly Young

Edited by
- Andre Sofair, MD, MPH

Gabapentin and pregabalin may cause serious breathing problems in patients who have respiratory risk factors, such as using opioids or other central nervous system depressants, having an underlying respiratory condition like chronic obstructive pulmonary disease, or being elderly, according to a safety update from the FDA.

The agency notes that use and misuse of gabapentinoids have been increasing. Combining these with opioids or other CNS depressants (e.g., anti-anxiety medicines, antidepressants, antihistamines) increases the risk for respiratory depression. The FDA is requiring manufacturers to add this warning to the labels of gabapentin and pregabalin.

The agency received 49 case reports of gabapentinoids and respiratory depression over 5 years. Twelve people died, and they all had at least one risk factor. Small randomized trials in healthy people also found that gabapentinoids alone or with opioids depress respiratory function.

Clinicians should prescribe patients the lowest possible dose of gabapentinoids and monitor them for respiratory depression and sedation when coprescribing gabapentinoids with other high-risk drugs.

Link(s):
FDA MedWatch safety alert (Free) http://response.jwatch.org/t?ctl=6E998:5FF9B588B7CB016C9CAED415F02A60C4D2B71D9A95FA21D3&

Background: NEJM Journal Watch Psychiatry coverage of gabapentinoids and adverse events (Your NEJM Journal Watch subscription required) http://response.jwatch.org/t?ctl=6E999:5FF9B588B7CB016C9CAED415F02A60C4D2B71D9A95FA21D3&

 

How many lives have we lost due to the mistaken confidence that these drugs are very safe? Many lives have been lost because governments left physician education on opioids up to drug companies.

 

Nothing in life is 100% safe. One of the more common means of untimely death is falling in the bath, typically someone over 50, head hits stone-hard surface from standing height, that’s it.

Modern medicine has many failings but I’ll hazard an uneducated, just-my-impression guess that it was far, far worse 100 years ago but no such records were kept. Or take a different ‘innocent’ culture: if the witch doctor prescribes something you’re allergic to, ignores signs of a heart attack, offers a virgin (for a price) as your cure for HIV (not a joke, that was an accepted practice) and you die as a result, there’s no national registry of such events.

Speaking of witch doctors, perhaps we have a few nearby and now, instantiating with the a title starting with “Psych-“.

 

If people only took opioids and gabapentin and pregabalin the way they are prescribed it would save a lot of deaths too. We are lucky to live in a time where relief for pain is available but it is getting harder and harder to get because some people abuse them.

One headline was about the dangers of pregabalin but when you read it they were talking about people taking many tablets at a time.

 

@Sisyphus, agreed medicine has many failings. Included in this are pharmaceutical companies who minimized the addictive nature of opioids. Hence, law suits we have seen, and will continue to see for some time. And, government agencies such as the FDA who it seems, (as per recent article in the Globe and Mail), turned education re these drugs over to the pharmaceutical industry.

From the Health Canada website, a fact sheet on the opioid crisis:

Are Canada’s prescription opioids contributing to the crisis?
The opioid crisis is a complex issue. Illegal drugs with fentanyl added to them are
causing many of the opioid-related harms and deaths. However, prescription opioids have also contributed to the crisis. While opioids offer benefits, they also come with risks. High rates of opioid prescribing mean that more people are being exposed to the risks of opioids. (my
bolding)

The fact sheet below goes on to say from 2016 until 2019/04/09 (which I think means April 9, 2019), there were 9,000 deaths from opioids. In 2017 11 people per day in Canada died from these drugs:

https://www.canada.ca/en/health-can...y-living/canada-opioid-crisis-fact-sheet.html

One hundred years ago it was likely worse in some respects because we had less
social safety nets, and less treatments for disease. Things like sanitation, and nutrition were sometimes worse depending on circumstances. However, we should be doing better now than having the failings we do, such as wealthy industries fudging facts about how harmful some of their
products can be, and government agencies giving up their responsibilities to industries with vested interests.

ETA: corrected "9,000"

 

My emphasis :

I was put on pregabalin some years ago. What I needed was something for pain, but I'm female so my pain couldn't possibly be real, I must be anxious instead. (sarcasm off).

I refused to take it after about 2 months because I was sleeping for about 18 hours out of every 24. I didn't/don't have much of a life anyway, but pregabalin made me lose most of what I did have.

 

This is true, but distorts the facts. The risk of opioid prescribing is that some people use them to deal with other problems in their lives so take higher and higher doses. If they had not been prescribed them in the first place, it would never have happened. So over prescribing and giving them when another painkiller would be adequate is not right.

Taking an adequate amount to relieve pain and staying within that limit carries very little risk especially compared to the risk of living with severe pain. One doctor has written articles trying to bring attention to the fact that not prescribing enough opioids could be adding to the death rates. He thinks that people are having their dose reduced so that their bodies are stressed by the pain leading to things like deadly heart attacks. When they are examined after death they have opioids in their system and it is put down to an overdose when the opposite is true.

Adequate pain relief is very important. The nerves work by pain gates. If pain is bad these gates open so milder pain is felt as severe. By giving adequate pain relief after operations using machines to self administer less drugs need to be given in the long run.

Also after orthopaedic injury adequate pain relief makes it easier to move and the more movement you can do the sooner the injury will heal. It worries me that these breakthroughs are getting lost under a blanket opiods are bad mantra.

A friend was unable to have a hip replacement until her asthma was stabilised. in the meantime, she was put on a regime of paracetamol and NSAIDS with tramadol, gabapentin and oxycodone so she could sleep.

When she finally had her operation, despite 3 years of this regime she was off all the drugs within 6 weeks. The opioids she just reduced gradually over that time.

We have enough problems without being categorized as drug addicts while struggling to get enough to kill the pain or find a doctor to give them to us at all. Even the CDC was forced to admit that things had gone too far.

 

Kaolin and morphine appears to have been banned - can't get it any more (at least last time I tried). Goodness knows why - because of a tiny amount of morphine? I always used to keep some in case of an attack of diarrhoea. Eventually there was only a disgusting-tasting version, and then nothing.

 

Very much agreed, many need strong pain killers, but improved medical management, and informing patients is needed.

The loss of life due to incorrect use of prescription opioids has had an enormous reach, affecting many families.