Objective: To report and discuss a case of rhabdomyolysis in an elderly patient with neuropathic pain who was treated with gabapentin.
Case summary: An 85-year-old diabetic woman was hospitalized for severe pain in her lower limbs and difficulty in walking, compromising her daily activities. On admission, the woman's laboratory parameters, including creatine kinase (CK) and myoglobin, were in the normal range. Neurologic evaluation suggested a diagnosis of diabetic neuropathic pain, and therapy with gabapentin 150 mg 3 times daily was started. On the same day, the patient developed psychomotor agitation and gastric pain, which were treated with haloperidol 10 mg and lansoprazole 30 mg, respectively. In the following hours, the severity of muscular pain increased and the patient developed myopathy with acute renal failure (CK 459 U/L, myoglobin 11 437 ng/mL, creatinine 4.59 mg/dL), which worsened progressively during the next 2 days (CK 3095 U/L, myoglobin 17,000 mg/dL, creatinine 4.77 mg/dL) despite discontinuation of haloperidol and lansoprazole. No signs of trauma or edema, suggesting possible compartmental or crush syndrome, were detected. Gabapentin was then withdrawn and the patient's condition rapidly improved. Complete recovery followed in about 10 days.
Discussion: Severe myopathy is an unexpected adverse reaction to gabapentin therapy. In this patient, a possible contribution of haloperidol or lansoprazole to the adverse event cannot be excluded. However, worsening of the clinical picture despite discontinuation of these drugs, together with rapid improvement observed after withdrawal of gabapentin, strongly suggest a causative role of gabapentin. According to the Naranjo probability scale, gabapentin was the probable cause of myopathy in this patient. The mechanism by which gabapentin may induce myopathy is unknown. The early onset of the syndrome after initiation of treatment with gabapentin in therapeutic doses is compatible with the picture of an idiosyncratic adverse response.
Conclusions: Pathogenetic and clinical investigations are required to explore what mechanisms account for gabapentin-related muscular alterations at the time of onset, including electromyographic recordings as well as muscle and nerve histopathologic examinations. Until more information is available, clinicians should consider the possibility of discontinuing gabapentin treatment in patients showing muscular pain and signs of myopathy.