Gabapentin: when to use it and when to be careful

 The Hidden Risks of Gabapentin – Uses and Cautions

Gabapentin, a medication initially developed for epilepsy, has surged in popularity, with millions of prescriptions annually. Most ophthalmologist like myself will prescribe it, rarely for neuropathic pain or trigeminal neuralgia. While effective for specific conditions, its widespread off-label use and emerging risks, including a potential link to dementia, raise concerns. Here’s what you need to know about gabapentin’s uses and dangers.

FDA-Approved Uses

Gabapentin is approved for:

•  Partial seizures (with other medications) in adults and children over 3.

•  Postherpetic neuralgia (nerve pain after shingles) in adults.

•  Restless legs syndrome (gabapentin enacarbil, brand name Horizant).

Off-Label Uses

Up to 95% of gabapentin prescriptions are for unapproved conditions, including:

•  Neuropathic pain (e.g., diabetic neuropathy, sciatica)

•  Bipolar disorder

•  Anxiety disorders

•  Alcohol withdrawal

•  Migraine prevention

•  Fibromyalgia

•  Hot flashes

•  Attention deficit disorder

•  Trigeminal neuralgia

•  Periodic limb movement disorders

•  Premenstrual syndrome

Dangers of Gabapentin

Recent research and FDA warnings highlight significant risks:

•  Dementia and Cognitive Impairment: A 2025 study found that chronic back pain patients with multiple gabapentin prescriptions had a 29% higher dementia risk and an 85% higher risk of mild cognitive impairment, with younger adults (ages 35–64) facing over double the risk.

•  Respiratory Depression: Combining gabapentin with opioids or other depressants can cause life-threatening breathing problems, especially in older adults or those with lung conditions.

•  Misuse Potential: Gabapentin’s euphoric effects have led to rising abuse, particularly among those with substance use histories.

•  Side Effects: Drowsiness, dizziness, and coordination issues are common, increasing fall risks. Blurry vision and concentration difficulties also occur.

•  Withdrawal: Stopping abruptly can trigger seizures or worsen symptoms, requiring careful tapering.

•  Questionable Efficacy: Many off-label uses lack strong evidence, offering minimal pain relief in studies.

Why It Matters

Gabapentin’s off-label prescribing, driven partly by past aggressive marketing and the search for opioid alternatives, has outpaced evidence of its safety and efficacy. The recent dementia link underscores the need for caution, especially for long-term use in younger patients.

Takeaway

Gabapentin can be a valuable tool for approved uses, but its risks—dementia, respiratory issues, and abuse potential—demand careful consideration.