The antiseizure medication tiagabine (Gabitril) has been used off-label to manage neuropathic pain, either diabetic or spinal in nature. It has also been helpful in treating insomnia. Start with 2 mg at night (4 mg in younger adults or those who do not suffer sedative side effects from narcotics). For maximum pain relief, the total daily dose can be increased to 32 mg in divided doses. This is a useful alternative for treating neuropathic pain without escalating narcotic medications. — KATHLEEN LAPPIN, MSM, PA-C, Sarasota, Fla.

The antiepileptic drugs phenytoin and carbamazepine have been used to treat chronic pain for decades. Newer drugs, like tiagabine, are currently being touted for the same purpose. The tiagabine dose suggested is certainly reasonable (up to 56 mg per day is used to treat epilepsy). However, clinicians should be concerned about the increasing tendency to prescribe antiepileptic drugs before other alternatives have been pursued. Antiepileptics are expensive and not without serious side effects (e.g., agranulocytosis). In fact, tiagabine is so new that the full extent of its side-effect profile is listed as “unknown.” It would be prudent to try a cheaper, older drug first. Start with phenytoin or even low-dose amitryptiline (25-50 mg at bedtime), which is known to be effective and safe for both sedation and chronic pain. — Reuben W. Zimmerman, PA-C (145-15)