Pregabalin (Lyrica) Dosing Recommendations
The recommended starting dose for pregabalin is 75 mg twice daily (150 mg/day), which can be titrated to 150-600 mg/day divided into two or three daily doses based on efficacy and tolerability. 1, 2
Initial Dosing and Titration
- Starting dose: 75 mg BID (150 mg/day) or 50 mg TID
- Therapeutic dose range: 150-600 mg/day
- Maximum recommended dose: 600 mg/day, though doses above 450 mg/day show limited additional benefit with increased adverse effects 2
- Titration schedule:
- Start with 75 mg BID
- May increase to 150 mg BID (300 mg/day) within 1 week based on efficacy and tolerability
- For patients who don't experience sufficient pain relief after 2-3 weeks at 300 mg/day, may increase to 225 mg BID (450 mg/day)
Indication-Specific Dosing
Neuropathic Pain
- Diabetic peripheral neuropathy: 150-300 mg/day in divided doses 1
- Postherpetic neuralgia: 150-600 mg/day in divided doses 1, 3
- Neuropathic pain associated with spinal cord injury: 150-600 mg/day in divided doses 2
Other Indications
- Partial-onset seizures: 150-600 mg/day in divided doses 4
- Fibromyalgia: 300-450 mg/day in divided doses
Renal Dose Adjustment
Pregabalin is primarily eliminated by renal excretion, requiring dose adjustment in renal impairment 1, 2:
| Creatinine Clearance (mL/min) | Total Daily Dose Range (mg/day) | Dose Regimen |
|---|---|---|
| ≥60 | 150-600 | BID or TID |
| 30-59 | 75-300 | BID or QD |
| 15-29 | 25-150 | QD or BID |
| <15 | 25-75 | QD |
For hemodialysis patients: Administer supplemental dose immediately following each 4-hour hemodialysis treatment 2
Duration of Trial and Efficacy Assessment
- Allow 3-8 weeks for titration plus 2 weeks at maximum tolerated dose to assess efficacy 1
- If no benefit is observed after an adequate trial, consider discontinuation
- Taper gradually over at least 1 week when discontinuing to avoid withdrawal symptoms 1
Monitoring and Adverse Effects
Common adverse effects include:
- Dizziness (up to 49%)
- Somnolence (up to 50%)
- Peripheral edema (7%)
- Gait disturbance (14%)
- Weight gain 1, 4
Monitor for:
- Adverse effects at each dose increase
- Renal function, especially in elderly patients or those with known renal impairment
- Visual field changes (rare but reported)
Clinical Pearls
- Pregabalin has better bioavailability (>90%) than gabapentin and more predictable pharmacokinetics 1, 5
- Reaches steady state within 24-48 hours 1, 6
- No clinically significant drug interactions via cytochrome P450 system 5
- Can be taken with or without food 5
- Underdosing is a common mistake in clinical practice; ensure adequate dosing for therapeutic effect 1
- Avoid overly rapid titration, which increases risk of adverse effects 1
Pregabalin offers advantages over gabapentin including faster onset, better bioavailability, and simpler dosing, making it a preferred option for many neuropathic pain conditions when cost is not a limiting factor 1, 7.