TABLE 8

Analgesic Dosing Guidelines and Suggested Titration Schedules

Gabapentin
 Days 1–3: 2 mg/kg (100 mg maximum), enterally, 3 times daily
 Days 4–6: 4 mg/kg, enterally, 3 times daily
 Increase every 2–4 days by 5–6 mg/kg per day until the following92:
  1. Effective analgesia reached (may be noted at 30–45 mg/kg per day)
  2. Side effects experienced (nystagmus, sedation, tremor, ataxia, swelling)
  3. Maximum total dose of 50–72 mg/kg per day reached (2400–3600 mg/day)
  4. Younger children (<5 years) may require a 30% higher mg/kg per day dosing, such as a total dose of 45–60 mg/kg per day13,103,104
  5. Half of the total daily dose may be given as the evening dose if symptoms occur mostly in the evening and overnight
  6. Titrate more rapidly for severe pain or as tolerated, titrate more gradually if sedation noted
Pregabalin
 Days 1–3: 1 mg/kg (50 mg maximum), enterally, every night
 Days 4–6: 1 mg/kg, enterally, twice daily
 Increase every 2–4 days up to 3 mg/kg per dose, enterally, given 2 or 3 times daily (maximum 6 mg/kg per dose)
Amitriptyline or nortriptyline
 Days 1–4: 0.2 mg/kg (10 mg maximum), enterally, every night92
 Days 5–8: 0.4 mg/kg, orally, every night
 Increase every 4–5 days by 0.2 mg/kg per day until the following92:
  1. Effective analgesia, side effects (constipation, dry mouth, urinary retention, sedation), or dosing reaches 1 mg/kg per day (50 mg/day maximum)
  2. Consider ECG before further dose escalation up to 1.5–2 mg/kg per day (100 mg/day maximum); higher rate of side effects with higher doses including anticholinergic
  3. Consider plasma level if concerns with gastrointestinal tract absorption
  4. Consider twice-daily dosing of 25%–30% in the morning and 70%–75% in the evening
Clonidine
 Days 1–3: 0.002 mg/kg (0.1 mg maximum), enterally, every night
 Days 4–6: 0.002 mg/kg, enterally, twice daily
 Days 7–9: 0.002 mg/kg, enterally, 3 times daily
 Increase every 2–4 days by 0.002 mg/kg until the following:
  1. Effectiveness noted or side effects develop
  2. Titrate more rapidly if tolerated
  3. Average dose in 1 study (for spasticity): 0.02 mg/kg per day108
  4. 0.002–0.004 mg/kg every 4 hours as needed for breakthrough episodes that suggest autonomic storm events (suggested by facial flushing, muscle stiffening and tremors, hyperthermia)
  • Data from refs 13,45,9295,103,104,108. ECG, electrocardiogram.