Association of Gabapentin Use With Pain Control and Feeding Tube Placement Among Patients With Head and Neck Cancer Receiving Chemoradiotherapy

Abstract

Almost one-half of patients treated with radiotherapy (RT) for oropharyngeal cancer require chronic opioid use to manage oral mucositis (OM) pain. 1 Given the paucity of level 1 evidence for OM pain management, current guidelines allow consideration of prophylactic gabapentin. 2,3 However, the optimal dose remains unclear. In this comparative effectiveness study, we performed a secondary analysis of 2 clinical trials conducted by this research team, hypothesizing that a higher dose of gabapentin would be associated with less opioid use and feeding tube (FT) placement. MethodsEligible patients in both studies received concurrent chemoradiotherapy for nonmetastatic squamous cell carcinoma of the head and neck and prophylactic oral gabapentin (titrated to 900 mg vs 2700 mg daily in 1 study 4 and 3600 mg daily in the other study). Using the 3600 mg cohort as the reference group, we performed a multivariable competing risks analysis to evaluate time to first use of opioids and a logistic regression analysis to assess FT placement, adjusted for baseline characteristics. This study followed the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) reporting guideline. Additional information is available in eMethods in the Supplement. ResultsAmong 92 patients, the median age was 62.1 years (IQR, 55.4-66.4 years); 82 patients were male (89.1%), and 10 (10.9%) were female. Baseline cohort characteristics were well balanced (Table ).Most patients tolerated gabapentin per protocol. For example, adverse effects from gabapentin, such as dizziness and drowsiness, were only reported in 1 patient (3.1%) in the 3600 mg cohort (grade 3 dizziness) and 2 patients (6.3%) in the 3600 mg cohort (gabapentin was discontinued because of nausea and vomiting partly associated with RT and low adherence to oral hygiene).The multivariable competing risks model revealed the time to first opioid use for additional pain control was greatest in the 3600 mg cohort (Figure). The proportion of patients requiring opioids during RT was also smallest in the 3600 mg cohort (12 patients [37.5%]) vs the 900 mg cohort (27 patients [93.1%]) and the 2700 mg cohort (19 patients [61.3%]; P < .001). Multivariable logistic regression analysis revealed that, compared with the 3600 mg cohort (3 patients [9.4%]), the 2700 mg cohort (14 patients [45.2%]) had significantly greater odds of FT placement during RT (adjusted odds ratio, 9.9; 95% CI, 2.1-75.7; P = .009); however, the odds were not significantly greater in the 900 mg cohort (6 patients [20.7%]; adjusted odds ratio, 3.6; 95% CI, 0.7-28.1; P = .15). DiscussionThis study is, to our knowledge, the first evaluation of prospective data to suggest that higher doses of gabapentin (900-3600 mg daily) are well tolerated and associated with delayed time to first

Obesity and Survival After Immune Checkpoint Inhibition for Head and Neck Squamous Cell Carcinoma

“…A retrospective, single-institution cohort study of 445 patients with head and neck cancer of various types and treated with chemoradiotherapy found that pretreatment overweight BMI, but not obesity BMI, was an independent factor associated with improved OS and progression-free survival (PFS). 14 Zhang et al 15 conducted a retrospective review of 49 patients at a single institution in China who received anti-PD-1 therapy (pembrolizumab) for recurrent or metastatic HNSCC. They found that patients with pretreatment obesity and overweight BMI with recurrent or metastatic HNSCC had significantly improved OS and PFS, while patients with underweight BMI had worse outcomes.…”

Severe Oral Mucositis After Intensity-Modulated Radiation Therapy for Head and Neck Cancer

“… 16 For OM pain control, we prescribe all eligible patients prophylactic gabapentin and recommend alternating between over-the-counter acetaminophen and nonsteroidal anti-inflammatory drugs before prescribing opioids. The use of prophylactic gabapentin is controversial, with multiple studies 34 , 35 , 36 , 37 , 38 showing it can reduce and delay opioid use in patients with HNC, while a placebo-controlled randomized clinical trial 39 found it to have no pain control benefit. Consistent with prior reports, 4 , 5 , 6 we found severity of OM to be associated with opiate use.…”

“…The use of prophylactic gabapentin is controversial, with multiple studies [34][35][36][37][38] showing it can reduce and delay opioid use in patients with HNC, while a placebo-controlled randomized clinical trial 39 found it to have no pain control benefit. Consistent with prior reports, [4][5][6] we found severity of OM to be associated with opiate use.…”

Prognostic utility of the geriatric nutritional risk index for head and neck cancer: Systematic review and meta‐analysis

“…9,10 Nutritional markers, such as serum albumin and body mass index (BMI), have been reported to have an association with patient survival in individuals with HNC. 11,12 Bouillanne et al developed the geriatric nutritional risk index (GNRI), which uses the following equation to calculate nutritional risk: GNRI = 14.89 Â albumin (mg/dL) + 41.7 Â (current weight/ideal body weight). The GNRI is used to determine susceptibility to malnutrition and related complications in older adult patients.…”