Authors: Michael Vlessides
Anesthesiology News
Administration of gabapentinoids on the day of arthroplasty is associated with several negative postoperative outcomes, including naloxone use, noninvasive ventilation, mechanical ventilation and ICU admission, according to a large database analysis. The study also found no improvement in hospital length of stay or opioid consumption with gabapentinoids.
“Gabapentinoids have been increasingly utilized in ERAS [enhanced recovery after surgery] protocols that seek to minimize opioid consumption,” said Sean Moore, MD, MBA, a resident at Duke University Medical Center, in Durham, N.C. “We have similar protocols at Duke, and have noticed that our patients are often sleepy after receiving gabapentin.”
The study is particularly relevant given the increasing number of total hip and knee arthroplasty surgeries, which now total more than 1 million annually in the United States. “About 25% of those people are receiving gabapentinoids as part of multimodal analgesic protocols.
“Our goal was to build on that previous research using a much larger population,” Dr. Moore said.
Dr. Moore and his colleagues examined data from the Premier database, a multicenter data repository for U.S. hospitals. Patients undergoing primary total knee or hip arthroplasty between 2009 and 2014 were included in the analysis.
The researchers examined charge codes for gabapentinoid administration on the day of surgery and determined its association with naloxone use, noninvasive ventilation, invasive mechanical ventilation and ICU admission.
“We also looked at hospital length of stay and opioid consumption to see if patients were getting benefit from gabapentinoids,” Dr. Moore said. “We essentially wanted to clarify the risks and benefits of giving someone gabapentinoids: Is the juice worth the squeeze?”
The investigators adjusted for several covariates, including patient and hospital demographics, type of anesthesia and other analgesics used.
As Dr. Moore reported at the 2019 annual meeting of the International Anesthesia Research Society (abstract D157), 436,274 patients were identified across 605 hospitals. Of these, 66,750 (15.3%) received gabapentinoids on the day of surgery. Interestingly, individuals who received gabapentinoids were more likely to be patients at large teaching hospitals, where the agent was more likely to be coadministered with acetaminophen and celecoxib (Celebrex, Pfizer).
“The first interesting thing we found was that in 2009, gabapentinoid administration on the day of surgery was 10%,” Dr. Moore noted. “It jumped all the way to almost 27% by 2014, and I can only imagine that it’s continued to rise since then.”
The analysis also found that perioperative gabapentin exposure was associated with poorer outcomes. The adjusted odds ratio for naloxone use after surgery was 1.95 (95% CI, 1.75-2.23; P<0.001). Similarly, adjusted odds ratios were found to be 1.37 for noninvasive ventilation (95% CI, 1.28-1.47; P<0.001), 1.66 for intensive mechanical ventilation (95% CI, 1.14-1.62; P=0.0008), and 1.29 for ICU admission (95% CI, 1.17-1.42; P<0.001).
“So, we found that gabapentinoids are associated with respiratory depression in all of our primary outcomes, and this is pretty consistent with previous data on the topic,” Dr. Moore said in an interview with Anesthesiology News.
Furthermore, the analysis did not find many clinical benefits associated with gabapentin administration; in fact, hospital lengths of stay were slightly longer in the gabapentin group. In contrast, pre-discharge opioid consumption favored patients in the gabapentinoid group, who consumed 0.38 mg less parenteral morphine equivalents than their counterparts who did not receive gabapentinoids.
Given these findings, the researchers were confident that there was little reason to administer gabapentinoids in this surgical population. “Our conclusion is that the juice is not worth the squeeze, at least in this patient population,” Dr. Moore said. “There are better data for opioid reduction with gabapentin administration in procedures such as spine surgery. But when it comes to total hip and knee replacements, we just didn’t find a lot of benefit.”
Dr. Moore recognized that gabapentin is still being used at his institution, although its popularity may be declining as a result of the trial. “Gabapentinoids are part of our ERAS protocol and it’s up to the attending as to whether they want to give it,” he said. “However, I have seen fewer of my attendings writing for perioperative gabapentin because of some of the work that we’ve done.”
Stavros G. Memtsoudis, MD, PhD, MBA, told Anesthesiology News that he does not understand why agents such as gabapentin have gained such popularity in these clinical situations. “What is surprising to me is this surge in the use of these kinds of medications based on very poor data,” said Dr. Memtsoudis, the director of Critical Care Services and a senior scientist at the Hospital for Special Surgery, in New York City. “Unfortunately, it seems that many clinicians, in their rush to get rid of opioids, are jumping on anything that could remotely be of benefit.”
Dr. Memtsoudis noted that the search for alternatives to opioids may not be necessarily helping patients. “More and more people are turning to untested agents like expensive new formulations of established drugs or antidepressants to help reduce pain and opioid consumption. There are no good data to support this practice, but people are so desperate that they’re willing to put the carriage before the horse, likely to find out later that they probably did more harm than good.
“The answer is not trying to get rid of opioids but to use them more responsibly, because they do have a legitimate role in postoperative pain management,” Dr. Memtsoudis said. “Perhaps we are trying to do too much in the name of fighting the opioid epidemic, promoting early recovery after surgery and other academic initiatives, without the data to support our decisions.”
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