Gabapentin is structurally related to GABA. However, it does not bind to GABAA or GABAB receptors, and it does not appear to influence synthesis or uptake of GABA.

High affinity gabapentin binding sites have been located throughout the brain; these sites correspond to the presence of voltage-gated calcium channels specifically possessing the alpha-2-delta-1 subunit.

Gabapentin 800 mg Tab-IVA
Gabapentin 800 mg Tab-IVA

This channel appears to be located presynaptically, and may modulate the release of excitatory neurotransmitters which participate in epileptogenesis and nociception.

Absorption

Variable, from proximal small bowel by L-amino transport system; saturable process; dose-dependent

Vd: 58 ± 6 L; CSF concentrations are ~20% of plasma concentrations

Metabolism

Not metabolized

Excretion

Proportional to renal function; urine (as unchanged drug)

Clearance: Apparent oral clearance is directly proportional to CrCl: Clearance in infants is highly variable; oral clearance (per kg) in children <5 years of age is higher than in children ≥5 years of age

Time to Peak

Immediate release: Infants 1 month to Children 12 years: 2 to 3 hours; Adults: 2 to 4 hours; Extended release: 8 hours

Half-Life Elimination

Infants 1 month to Children 12 years: 4.7 hours

Adults, normal: 5 to 7 hours; increased half-life with decreased renal function; anuric adult patients: 132 hours; adults during hemodialysis: 3.8 hours

Protein Binding

<3%

Gabapentin, available only as oral preparations, is absorbed in the small intestine by a combination of diffusion and facilitated transport. Its transport from the gut following oral administration is facilitated by its binding to an, as yet unidentified, receptor linked to a saturable ‐amino acid transport mechanism . As this carrier‐dependent transport is saturable, the bioavailability of gabapentin varies inversely with dose. The bioavailability of a 300‐mg dose is ≈ 60% , whereas that of a 600‐mg dose is ≈ 40% [8], and this decreases to ≈ 35% at␣steady state with doses of 1600 mg three times daily [9].␣Peak plasma levels (max) of gabapentin of 2.7–2.99 mg.l−1 are achieved 3–3.2 h after ingestion of a single 300‐mg capsule . As a result of the dose‐dependent saturable absorption of gabapentin, max increases less than threefold when the dose is tripled from 300 to 900 mg .

Its extensive distribution is reflected in a volume of distribution of ≈ 0.6–0.8 l.kg−1. Cerebrospinal fluid (CSF) concentrations are 20% of plasma concentrations [11] and have been estimated at between 0.09 and 0.14 µ g.ml−1. Brain tissue concentrations are ≈ 80% the plasma level [13]. In rats, the pancreatic and renal tissue concentrations were found to be eight and four times, respectively, higher than serum concentrations. Pancreatic accumulation of the drug does not occur in humans as it exists in a highly ionised state at physiological pH and concentrations in adipose tissue are low.

Gabapentin is not metabolised in humans and is eliminated unchanged in the urine. It undergoes first‐order kinetic elimination and renal impairment will consequently decrease gabapentin elimination in a linear fashion with a good correlation with creatinine clearance . The elimination half‐life of gabapentin is between 4.8 and 8.7 h . Gabapentin is removed by haemodialysis, so patients in renal failure should receive their maintenance dose of gabapentin after each treatment . Unlike other anticonvulsant drugs, it does not induce or inhibit hepatic microsomal enzymes.

Interactions

Gabapentin is conspicuous among anticonvulsant drugs for its lack of clinically relevant drug interactions, because of the lack of hepatic metabolism and ability to induce or␣inhibit hepatic microsomal enzymes, and low protein binding. No pharmacokinetic interaction has been demonstrated with other anticonvulsant drugs. Cimetidine, however, decreases the clearance of gabapentin by 12% because cimetidine decreases glomerular filtration rate . Busch et al . reported that antacids reduce the bioavailability of gabapentin by ≈ 20% when given concomitantly with, or up to 2 h post, gabapentin administration .

 

Mechanism of action

Gabapentin has no direct GABAergic action and does not block GABA uptake or metabolism. Gabapentin blocks the tonic phase of nociception induced by formalin and carrageenan, and exerts a potent inhibitory effect in neuropathic pain models of mechanical hyperalgesia and mechanical/thermal allodynia.

Gabapentin binds preferentially to neurons in the outer layer of the rat cortex at sites that are distinct from other anticonvulsants . It is likely that gabapentin acts at an intracellular site as the maximal anticonvulsant effect is achieved 2 h after an intravenous injection of gabapentin in rats. This occurs after the plasma and interstitial fluid concentrations have peaked and reflects the additional time required for intraneural transport.

Several theories have been proposed to explain the cellular mechanism of its anticonvulsant effect. The most favoured theory involves an interaction with an as yet undescribed receptor linked with the ‐system amino acid transporter protein. Suman Chauhan et al . demonstrated that ‐amino acids potently inhibited binding of an␣active enantiomer of gabapentin ([3H]gabapentin). This was further supported by Taylor et al .  who showed that the potent anticonvulsant, 3‐isobutyl GABA (an analogue of gabapentin) potently and stereoselectively bound to the same receptor. These findings renewed interest in the isolation of the receptor protein that may responsible for this anticonvulsant effect.

Other proposed biochemical events in the central nervous system (CNS) that may explain its anti‐epileptic effect include the increased extracellular GABA concentrations in some regions of the brain caused by an increase in activity of glutamic acid decarboxylase that produces GABA, and a decreased breakdown by GABA decarboxylase. Although a study, using magnetic resonance imaging (MRI) spectroscopy showed a global increase in GABA in the brain after the administration of gabapentin, there is no evidence that gabapentin increases intraneuronal GABA concentrations, binds GABAA or GABAB receptors, or exerts any GABA‐mimetic action.

Other effects of gabapentin have been described but are not considered to play a significant pharmacodynamic role. These include small decreases in the release of monoamine neurotransmitters (dopamine, noradrenaline and serotonin) and the attenuation of sodium‐dependent action potentials (suggesting sodium channel blockade) after prolonged exposure to gabapentin .

The mode of action of gabapentin in the treatment of neuropathic pain has not been fully elucidated. Although early studies  indicated that gabapentin had only a central anti‐allodynic effect, gabapentin has been shown to inhibit ectopic discharge activity from injured peripheral nerves . The mechanisms of the anti‐allodynic effects of gabapentin proposed include: CNS effects (potentially at spinal cord or brain level) due to either enhanced inhibitory input of GABA‐mediated pathways (and thus reducing excitatory input levels); antagonism of NMDA receptors; and antagonism of calcium channels in the CNS and inhibition of peripheral nerves . Of these, antagonism of the NMDA receptor and calcium channel blockade have the most supporting evidence. Field et al .  discounted an antihyperalgesic action via opioid receptor binding after demonstrating that morphine tolerance does not alter the efficacy of gabapentin and naloxone does not reduce its antihyperalgesic effect.

Research into a peripheral site of action for gabapentin has produced contradictory results. Intrathecal administration of gabapentin blocks thermal and mechanical hyperalgesia without affecting sympathetic outflow or acute nociception, and this suggests a spinal site of action. Patel et al .  demonstrated a presynaptic site of action for gabapentin in the rat spinal cord.

Although gabapentin does not bind to GABAA or GABAB receptors, increased synthesis and reduced breakdown of GABA have been described. Potentiation of inhibitory GABA‐ergic pathways seems unlikely to be responsible for its anti‐allodynic effect because GABA receptor antagonists do not reduce this effect .

The NMDA receptor complex is a ligand‐gated ion channel that mediates an influx of calcium ions when activated. The NMDA receptor complex has a number of binding sites for various ligands that regulate its activity, including the strychnine‐insensitive glycine binding site, phencyclidine binding site, polyamine binding site, redox modulatory site and a proton‐sensitive site. Partial depolarisation of the neuron after glutamine activation will release a magnesium plug and allow calcium influx into the neuron. These receptors are known to be found in high concentrations in the hippocampus and have been attributed a key role in the process of central sensitisation of painful stimuli, commonly known as the ‘wind‐up’ phenomenon, leading to hyperalgesia. Evidence linking gabapentin to the NMDA receptor follows research demonstrating the reversal of the antihyperalgesic effect of gabapentin by ‐serine, an agonist at the NMDA‐glycine binding site . However, receptor binding studies have failed to demonstrate a direct binding site for gabapentin at the NMDA receptor .

The α2δ subunit of the voltage‐dependent calcium channel is a binding site for gabapentin and the S‐isomer of pregabolin (S‐(+)‐3‐isobutylgaba) . Because only gabapentin and the S‐isomer of pregabolin produce antihyperalgesic effects, it is postulated that the antihyperalgesic action for gabapentin is mediated by its binding to this site on the voltage‐dependent calcium channel. Fink et al .  showed that, in the rat neocortex, gabapentin inhibits neuronal calcium influx in a concentration‐dependent manner by inhibiting P/Q‐type calcium channels. The decreased calcium influx reduces excitatory amino acid (e.g. glutamate) release leading to decreased AMPA receptor activation, and noradrenaline release in the brain. These findings support the hypothesis that calcium channel inhibition mediates the analgesic effects of gabapentin in chronic neuropathic pain. A decrease in potassium ion‐evoked glutamate release from rat neocortical and hipppocampal slices by gabapentin has been demonstrated .