How can I manage recurrent delayed sleep phase syndrome (DSPS) after reducing pregabalin (lyrica) dosage?

From the Guidelines

To wind back your body clock after reducing pregabalin, I recommend gradually shifting your sleep schedule earlier by 15-30 minutes each day while implementing consistent light therapy, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. This approach is supported by the guideline's emphasis on the use of timed light exposure to treat circadian rhythm sleep-wake disorders, including Delayed Sleep Phase Syndrome (DSPS) 1.

• Start by exposing yourself to bright light (ideally natural sunlight or a 10,000 lux light box) for 30 minutes immediately upon waking, even if that's in the afternoon initially.
• Then gradually move this light exposure earlier as you shift your bedtime earlier.
• Avoid bright lights and screens 2-3 hours before your target bedtime and consider taking 0.5-3mg of melatonin 2 hours before your desired sleep time, as the guideline suggests that melatonin can have direct soporific effects, particularly at higher doses 1. The gradual approach works better than trying to make dramatic shifts all at once, which can lead to the agitation you experienced, and is in line with the guideline's recommendation for a gradual adjustment of sleep-wake schedules 1. Consistency is crucial - maintain regular sleep-wake times even on weekends, avoid naps, exercise regularly (but not close to bedtime), and limit caffeine and alcohol, which can disrupt sleep architecture and timing. It's also important to note that reducing pregabalin from 150mg to 75mg may have unmasked your underlying circadian rhythm disorder, as pregabalin at higher doses can promote sleep 1. By following this approach and being consistent, you can help reset your circadian rhythm and improve your sleep quality, which is essential for overall health and well-being, as emphasized by the guideline's focus on improving physiologic circadian phase markers, total sleep time, and sleep onset time 1.

From the FDA Drug Label

When discontinuing pregabalin, taper gradually over a minimum of 1 week [see WARNINGS AND PRECAUTIONS (5. 6)]. The FDA drug label does not answer the question.

From the Research

Potential Solutions to Adjust the Body Clock

• Adjusting the sleep schedule can be challenging, but there are some strategies that may help, such as exposure to bright light therapy (BLT) in the morning to help regulate the circadian rhythm 2.
• Melatonin treatment can also be effective in promoting sleep onset and sleep maintenance, and can help advance or delay the phase of the circadian clock if administered in the evening or in the morning, respectively 3.
• It is essential to note that melatonin should be used in physiologic doses and at appropriate times to avoid disrupting the delicate mechanism of the circadian system 3.
• Other approaches, such as using melatonin agonists, may also be beneficial in treating circadian rhythm sleep disorders and insomnia 4.

Understanding the Role of Melatonin

• Melatonin plays a crucial role in regulating the circadian clock and sleep-wake cycle, and its dysregulation can lead to sleep and circadian disorders 2, 5.
• Melatonin is not just a sleep hormone, but rather a signal of darkness that reinforces nighttime physiology, including the timing of the sleep-wake cycle and other circadian rhythms 6.
• The sleep-wake cycle is controlled by a complex network of centers in the brain, and melatonin acts on the master circadian clock and sleep-related structures to regulate the sleep-wake rhythm 6.

Considerations for Treatment

• When using melatonin or melatonin agonists, it is essential to consider the potential risks and benefits, as well as the individual's specific needs and circumstances 3, 4.
• The development of new ligands that are highly selective for each melatonin receptor subtype may lead to new therapeutic agents for curing specific pathologies, including sleep disorders 6.
• A comprehensive approach that takes into account the individual's lifestyle, sleep habits, and environmental factors may be necessary to effectively adjust the body clock and improve sleep quality 5.