Gabapentin for Shingles: What to Know

Key Takeaways

One of the most common complications of shingles is postherpetic neuralgia, which causes severe pain that affects your quality of life. The good news is that postherpetic neuralgia can be managed with medications.
Gabapentin is an anticonvulsant drug that is most commonly used to treat seizures. However, it can also treat postherpetic neuralgia or pain that persists after an attack of shingles.
Other therapies used for the treatment of postherpetic neuralgia include tricyclic antidepressants (TCA) such as amitriptyline, antiviral therapy, and steroids, in addition to topical products for symptom relief.

Herpes zoster (HZ), commonly called shingles, is a viral infection that occurs due to the reactivation of the varicella-zoster virus, the same virus that causes chickenpox. Acute herpes zoster virus infections are characterized by a painful rash with blisters on a strip of skin. Occasionally, the acute pain continues even after the rash from an HZ infection is gone because of long-lasting damage to the nerve cells. This type of neuropathic pain is called postherpetic neuralgia.

Postherpetic neuralgia is one of the most common complications of shingles. It is often described as a severe pain that is burning, stabbing, tingling, or itching in nature. Post herpetic neuralgia can be severe enough to cause sleep disturbances, mood disturbances, loss of appetite, anxiety, and depression and affect your overall quality of life.

Please continue reading to learn more about gabapentin (brand name Neurontin), one of the medications used for the treatment of postherpetic neuralgia after shingles viral infections.

How does gabapentin help with severe pain from postherpetic neuralgia?

Gabapentin is an anticonvulsant drug that is used to treat seizures caused by epilepsy and restless leg syndrome (RLS). In addition to partial seizures, it is also used to treat postherpetic neuralgia or pain that persists after an attack of shingles. Gabapentin is classified as a gamma-aminobutyric acid (GABA) analogue. It is unclear exactly how gabapentin works. However, research has shown that gabapentin affects the excitability of the nerve cells (neurons). As a result, gabapentin plays a crucial role in preventing seizures. Regarding its role in the treatment of postherpetic neuralgia, gabapentin interferes with the transmission of pain signals and reduces the sensitivity to pain. Because of this mechanism of action, gabapentin is only effective at treating neuropathic pain or nerve pain. Therefore, gabapentin is not recommended for treating pain symptoms due to musculoskeletal injuries or arthritis.

It is worth noting that taking gabapentin during the acute phase of shingles has not been found to lower the risk of developing postherpetic neuralgia. The mainstay treatment for the acute phase of shingles consists of antiviral therapy with medications such as acyclovir, famciclovir, and valacyclovir. These antiviral agents can help to shorten the severity and duration of the illness. They work best if you take them as soon as possible after shingles rash onset.

How to take gabapentin for pain relief from nerve pain?

Gabapentin comes in the form of a capsule, tablet, extended-release tablet, solution, and suspension to take by mouth. The usual dose of gabapentin for shingles (post herpetic neuralgia) in adults is a 300-milligrams (mg) single dose on day 1, 300 mg twice a day (total 600 mg) on day 2, and 300 mg three times a day (total 900 mg) from day 3 onwards.

The dose can be increased as needed for pain relief, up to 600 mg three times a day (total 1,800 mg/day). Randomized controlled trials have shown that doses higher than 1,800 mg/day do not provide any additional benefit.

A once-daily extended-release formulation of gabapentin, sold under the brand name Gralise, is FDA-approved for the treatment of postherpetic neuralgia. Gralise comes as 300-mg and 600-mg tablets and can be titrated up to a dose of 1,800 mg per day for once-daily convenient dosing.

Read the prescription label carefully and take gabapentin exactly as prescribed. Do not change the dose or dosing frequency without your doctor’s approval. Do not substitute one formulation of gabapentin with another without checking with your doctor or pharmacist.

If you miss a dose of gabapentin, take it as soon as you remember. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not take a double dose or extra medicine to make up for a missed dose.

How long does it take for gabapentin to work for shingles?

Peak plasma concentration of gabapentin immediate-release formulation is achieved 2 to 3 hours after taking a dose. In healthy adults, this drug has a half-life of 5 to 7 hours (the time taken for the concentration of the drug to reduce to half its original amount). Therefore, gabapentin immediate-release needs to be dosed at least three times a day. Less frequent dosing of the regular tablets may not be successful in maintaining pain control. However, the extended-release tablets can be taken once daily. You should start to notice an improvement in your neuropathic pain after about 1 to 2 weeks of taking gabapentin regularly.

When should I stop taking gabapentin for shingles?

Nerve pain lasting 12 weeks or longer is common after shingles. Most people with postherpetic neuralgia need to take gabapentin for at least 4-6 weeks. If gabapentin provides good pain relief, your healthcare provider may continue you on this medicine until your neuropathic pain goes away. Your doctor will instruct you on how long you should take gabapentin. The duration and dosing regimen of gabapentin depends on your kidney function, medical history, and other concurrent medications.

What are the side effects of gabapentin for shingles?

Common adverse effects of gabapentin include drowsiness, dizziness, fatigue, loss of coordination, unsteadiness, nausea, vomiting, diarrhea, heartburn, constipation, dry mouth, headache, swelling of the hand and feet, double vision, blurred vision, unusual eye movements, anxiety, memory problems, strange or unusual thoughts, weight gain, cold and flu symptoms.

Clinical trials have shown that low patient compliance and discontinuation of gabapentin treatment is usually because of side effects such as nausea, drowsiness, and dizziness. Elderly patients are more likely to have these unwanted gabapentin side effects.

More serious adverse events include an allergic reaction with signs and symptoms such as a skin rash, hives, itching, swelling of the lips, tongue, and throat, trouble breathing, hoarseness, difficulty speaking, chest pain, a bluish tinge to the fingers and toes, confusion, extreme drowsiness, and seizures. Seek immediate medical attention if you develop these symptoms after taking gabapentin.

What are the risks of gabapentin treatment?

Some of the risks of taking gabapentin include:

Severe allergic reaction, including drug reaction with eosinophilia and systemic symptoms (DRESS), anaphylaxis (throat closing), and angioedema (swelling of the lips, tongue, and throat).
Risks while driving, operating heavy machinery, and doing other hazardous activities due to side effects like dizziness and drowsiness.
Drug interactions with certain medicines that also cause central nervous system depression, such as narcotic pain medicines.
Withdrawal seizures and status epilepticus (prolonged seizures) due to abrupt withdrawal of gabapentin.
Increased risk of suicidal thoughts and behavior.

Who should not take gabapentin?

Tell your healthcare provider if you have mental health conditions such as depression or mood changes, breathing problems, or kidney disease. Gabapentin should be used with caution in people with these medical conditions.

Tell your doctor about all your other medications, including prescription drugs, over-the-counter medicines, dietary supplements, and herbal products. Gabapentin can have drug interactions with antihistamines, antidepressants, anti-anxiety medications, nonsteroidal anti-inflammatory drugs such as naproxen (Aleve, Naprosyn), narcotic pain medicines (morphine, oxycodone, hydrocodone), other anticonvulsants, sedatives, sleeping pills, muscle relaxants, and tranquilizers.

What is the best painkiller for shingles?

The best painkillers for the treatment of postherpetic neuralgia include tricyclic antidepressants such as amitriptyline, anticonvulsants (calcium channel ligands) such as pregabalin and gabapentin, and topical agents such as lidocaine.

Gabapentin, pregabalin, and a 5% lidocaine patch are the only FDA-approved medications for the treatment of postherpetic neuralgia. Other medications are used off-label.

A placebo controlled clinical trial found that people with postherpetic neuralgia who received Gralise (gabapentin extended-release) 1,800 mg daily had a statistically significant reduction in their average pain score compared to those in the placebo group. The Gralise group in this placebo controlled study also reported reduced sleep interference due to pain and reported much or very much improved status on the patient's global impression of change.

How to prevent herpes zoster?

The shingles vaccine can help to lower your risk of developing shingles. The CDC recommends that adults above 50 years of age receive two doses of the recombinant zoster vaccine (Shingrix). The vaccine is also recommended for adults above 19 years of age who have weakened immune systems and are at a higher risk of getting shingles and its related complications like postherpetic neuralgia.

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