When should pregabalin (lyrica) be stopped in patients with Generalized Anxiety Disorder (GAD) and depression?

When to Stop Pregabalin in GAD and Depression

Pregabalin should be tapered gradually over a minimum of 1 week rather than discontinued abruptly to minimize withdrawal symptoms and potential increased seizure risk in patients with GAD and depression. 1

Discontinuation Criteria

Timeframe-Based Discontinuation

• Inadequate response: If the patient has not shown meaningful improvement in anxiety symptoms after 6-8 weeks at therapeutic doses (300-600 mg/day), consider discontinuing pregabalin 2, 3
• After symptom remission: Continue treatment for 4-9 months after achieving satisfactory response for a first episode of depression/anxiety 2
• Longer treatment: For patients with 2 or more previous episodes, longer maintenance therapy may be beneficial 2

Adverse Effect-Based Discontinuation

• Severe side effects: Discontinue if patient experiences:
  • Serious allergic reactions (swelling of face, mouth, lips, throat)
  • Severe respiratory depression, especially when co-administered with CNS depressants 1
  • Suicidal thoughts or behaviors 1
  • Intolerable dizziness or somnolence that persists despite dose adjustment 1

Tapering Protocol

Standard Tapering

• Taper pregabalin gradually over a minimum of 1 week 1, 4
• Reduce dose by approximately 50-100 mg every 3-7 days
• Monitor for withdrawal symptoms during tapering:
  • Insomnia
  • Nausea
  • Headache
  • Anxiety
  • Hyperhidrosis
  • Diarrhea 1

High-Risk Patient Tapering

• For patients on higher doses (>300 mg/day) or longer treatment duration:
  • Consider more gradual tapering over 2-4 weeks
  • Reduce by smaller increments (50 mg every 5-7 days)
  • More frequent monitoring for withdrawal symptoms 4

Monitoring During Discontinuation

• Schedule follow-up within 1-2 weeks after initiating taper 2
• Assess for:
  1. Withdrawal symptoms using standardized tools
  2. Rebound anxiety (which occurs in 0-6% of patients after 12-24 weeks of treatment) 4
  3. Return of depressive symptoms
  4. Sleep disturbances

Special Considerations

• Comorbid seizure disorders: Extra caution with tapering due to potential for increased seizure risk 1
• Elderly patients: May require more gradual tapering due to increased sensitivity to withdrawal effects
• Polypharmacy: If patient is on multiple psychotropic medications, coordinate tapering schedules carefully

Alternative Strategies

• Cross-titration: When switching to another medication, consider overlapping pregabalin taper with initiation of new medication
• Adjunctive therapy: If discontinuing due to partial response, consider adding CBT before complete discontinuation 5

Common Pitfalls to Avoid

1. Abrupt discontinuation: Can lead to withdrawal symptoms and increased seizure risk 1
2. Inadequate monitoring: Failing to follow up during the taper period
3. Ignoring mild withdrawal symptoms: Early intervention can prevent escalation
4. Overlooking rebound anxiety: May be mistaken for return of original condition

Pregabalin has demonstrated low potential for causing withdrawal symptoms when properly tapered 6, 4, but careful monitoring and gradual discontinuation remain essential to ensure patient safety and comfort.