Someone mentioned that if one takes more than 600 gabapentin, you should split the dose and taken part of it 2-3 hours before.

[SueJohnson]

It was recommended if taking a total of 900 mg to take 300 mg 2-3 hours before and then the 600 mg at the regular time. My question is if taking more than 900 mg (for pain), say 1100 mg, should one take 500 mg 2-3 hours before and then the 600 mg at the regular time?

[Hidden]

It may have been me. At least that's what I usually write.

I first came across the recommendation in this article

uptodate.com/contents/treat...

THe article actually suggests taking 1/3rd of the total dose earlier and the other 2/3rd of the dose later.

Easy if you're taking a dose that's divisible by three or if you have some 100mg capsules

900mg would be split 300mg earlier/600mg later

1100mg would be (about) 400mg earlier and about 700mg later.

The reasons behind this are first that gabapentin has a very variable absorption ratio. This means that for lower doses, say about 100mg up to 80% of it is absorbed. However, the higher the dose, the less of it is absorbed e.g. down to 27% or less.

This really begins to make a difference when you get up to 600mg.

Also, since gabapentin is absorbed in 3 hours taking two smaller dose 3 hours apart means that overall you actually absorb more of it.

The other consequence of this is that any increase over 1200mg will hardly make any difference despite splitting the dose. Hence, although the max dose is 2700mg it's probably not worth taking more than 1200mg.

One solution to this is to switch to pregabalin, The absorption ratio for this is 90% no matter how high the dose is. It only needs to be taken once a day and you can take up to 450mg (which is equivalent to 2700mg gabapentin).

pharmacytimes.com/view/how-...

(The maxiumum doses are based on the UK guidance for the management of RLS NICE 2020).

The linked article suggests taking gabapentin earlier than I usually say. I say later because from personal experience and other's comments I find if I take it too early, I wake up too early.

Hope this answers your question.

[SueJohnson in reply to Hidden]

Thank you. Is pregabalin also used for pain?

[Hidden in reply to SueJohnson]

Yes it is, neuropathic pain, anxiety and epilepsy.

[SueJohnson in reply to Hidden]

I looked at the link you gave and didn't see anything about dividing the dose 2/3 1/3

[Hidden in reply to SueJohnson]

It's under the heading Gabapentin

it says at the end of the paragraph

" The usual effective dose is 900 to 2400 mg daily given in a single dose or divided one-third at midday and two-thirds in the evening for maintenance doses ≥600 mg daily "

It's only my personal opinion that a midday dose is too early.

[danamias in reply to Hidden]

Hi. I take 400mg gabapentin plus 3mg of ropinirole at night which which seems to get me a night's sleep. I explained to my neurologist recently that I can't lie down at all during the day without the symptoms starting - and when they do I also experience an extremely muzzy head. The neurologist suggested I 'experiment' with the gabapentin across the day. I tried taking 400mg of gabapentin at midday and then a lie down at 2pm. Didn't work. But then again, I wasn't also taking the ropinirole. Not sure what to try next?

[Hidden in reply to danamias]

If you're taking ropinirole and experiencing symptoms during the day then this is augmentation.

The ropinirole is causing this.

Your best option is to increase the gabapentin and reduce and stop taking the ropinirole.

If gabapentin is prescribed on it's own, the minimum effective dose is 900mg, but it can be increased up to 2700mg. However, if more than 1200mg is needed then it's better to switch to pregabalin.

There's really no point in taking the gabapentin during the day, I doubt if it will work whilst you're suffering augmentation.

I'm afraid it does appear if your doctor is one of the many who are ignorant on how to manage RLS particularly when augmentation occurs. Many have never even heard of it.

You MUST not stop taking ropinirole suddenly. You must reduce it slowly. Each time you reduce the dose you may suffer withdrawal symptoms. It's usual to reduce it in steps of 0.5mg or less. You can then reduce it in no less than two weeks, or can wait for withdrawals to settle. As the dose gets lower, you might find withdrawals tend to get worse, in which case, you can either reduce in smaller steps e.g. 0.25mg and/or over more weeks.

Withdrawal effects include intensification of symptoms and sleeplessness. If the latter your doctor may agree to prescribea benzodiazepine to aid sleep.

Ask your doctor for blood tests for serum iron, transferrin and ferritin.

If you'r ferritin is less than 75, then you may benefit for starting an oral iron supplement. It's best not to take a prescription iron, better an over the counter one e.g. "Gentle "iron, ferrous bisglycinate.

If you are taking any other medications for any other condition then they may be making your RLS worse. This includes antidepressants, sedating antihistamines, some anatcids, some statins, some antiemetics, some blood pressure/heart tablets, non-potassium sparing diuretics and others.

Some foods/drinks can make RLS worse, particularly alcohol, sugar and caffeine. Different people have different food sensitivites so you might want to keep a food diary.

I suggest you look at the following web site. Particuarly look at the links on "scenario management" and "prescribing information" - "Augmentation". You cna also look at "prescribing information" = "pregabalin" and "Gabapentin"

If your DR would like to dispute anything I've written or dismiss it then refer him to this web site.

cks.nice.org.uk/topics/rest...

I would act quickly, once augmentation has set in, it makes it more difficult to treat RLS in the future.

[danamias in reply to Hidden]

Thank for this. Let me be clear about your advice. First, I need to withdraw from ropinirole because 1) it is the cause of my daytime augmentation 2) there's no point in me increasing gabapentin or using it during the day until I have fully withdrawn from gabapentin. Second, I'm fairly sure that it is the combination of ropinirole and gabapentin that allows me to sleep at night. So, if I start withdrawing from ropinirole then the symptoms are likely to start again at night and I won't be able to sleep. Perhaps I should raise the gabapentin as I reduce the ropinirole? Third, once I have withdrawn from ropinirole then I can start to use gabapentin during the day which then may allow me to lie down. Any thoughts? Thanks again 🙂

[Hidden in reply to danamias]

Hi, some clarification.

You can increase the gabapentin as you reduce the ropinirole.

Unfortunately, withdrawals, including sleeplessness are almost invevitable. This is one of the things that makes ropinirole such an hoirrendous drug, not just the augmentation but also the difficulty in withdrawing.

You can ask your doctor for a benzodiazepine or Z drug to help with sleep.

It's best to take all the gabapentin at night as this can also aid sleep.

Otherwise the best way to reduce withdrawal effects is to wean off the drug very slowly as I suggested.

As the ropinirole is reduced the daytime symptoms should settle. Once you've fully withdrawn from it, there should be no need to take anything except at night as the augmentation (i.e.symptoms in the day) should fade.

Don't forget the iron or aggravating factors, these can mak a signficant difference.

If you do luve in the UK look at the link I gave.

[danamias in reply to Hidden]

Thanks - appreciated

[danamias in reply to Hidden]

You've been really helpful - thank you. My RLS symptoms come on late afternoon and in the evening which I know is typical but at a time when I'm not taking any medication. As I said earlier, I only take ropinirole and gabapentin two hours before going to bed. So can this really be augmentation or simply the RLS symptoms as they would occur with without medication? If that's the case, then my be I'm not experiencing augmentation. Does that make sense or not?

[Hidden in reply to danamias]

Yes that makes sense.

If symptoms are occurring earlier but just in the evening then you could try taking the ropiniole earlier e.g. before the symptoms start if they start at a regular time.

This is a juggling act because if you take it earlier it will wear off earlier.

It may still be an early sign pf augmentation.

Do read up on augmentation though and if there's the slightest sign of augmentation starting you need to review the situation. Once you've suffered augmentation it can cause permanent damage and limit any future treatment options.

I suggest you read this link

cks.nice.org.uk/topics/rest...

[SueJohnson in reply to Hidden]

Unfortunately, here in the US pregabalin is very expensive. Eg for the equivalent of 900 mg 3X a day for gabapentin, it would cost almost $4,000/year. I might add Horizant is worse at $6000.

[Hidden in reply to SueJohnson]

I really am sorry, I only write which medicines might be most suitable. I have no idea what they cost.

[marsha2306]

I have been advised by my neurologist and my pain doc (for a different issue in addition to my RLS) that anything more than 1200 mg dose at one time does not give additional relief. I take 900 mg at 8:30 pm to give the gabapentin time to get into my system. When I initially took it at bedtime it kept me awake, therefore taking it earlier helped me.

[Hidden in reply to marsha2306]

Hi, as I wrote earlier (or was it somewhere else?), your docs are correct. If you need more than 1200mg gabapentin then it's better to switch to pregabalin.