Pregabalin (Lyrica): Uses and Dosage
Pregabalin (Lyrica) is indicated for neuropathic pain conditions including diabetic peripheral neuropathy, postherpetic neuralgia, and fibromyalgia, with recommended dosages ranging from 150-600 mg/day depending on the condition and patient factors.
Primary Indications
Neuropathic Pain
Diabetic Peripheral Neuropathy
Postherpetic Neuralgia
- Starting dose: 75 mg twice daily or 50 mg three times daily (150 mg/day) 1
- Recommended dose range: 150-300 mg/day 1
- For patients with insufficient pain relief after 2-4 weeks at 300 mg/day, dose may be increased to 600 mg/day 1
- Higher doses (600 mg/day) should be reserved for patients with ongoing pain who tolerate 300 mg/day 1
Fibromyalgia
Adjunctive Therapy for Seizures
- Partial-Onset Seizures (adults and pediatric patients ≥1 month)
Dosing Considerations
Administration
- Can be taken with or without food 1
- Typically administered in 2-3 divided doses daily 1
- When discontinuing, taper gradually over a minimum of 1 week to avoid withdrawal symptoms 1
Renal Adjustment
Pregabalin is primarily eliminated by renal excretion, requiring dose adjustment in renal impairment 1:
| Creatinine Clearance (mL/min) | Total Daily Dose Range (mg/day) | Dosing Regimen |
|---|---|---|
| ≥60 | 900-3600 | 300-1200 mg TID |
| >30-59 | 400-1400 | 200-700 mg BID |
| >15-29 | 200-700 | 200-700 mg QD |
| ≤15 | 100-300 | 100-300 mg QD |
Efficacy Comparison by Condition
- Postherpetic neuralgia: NNT 3.9 for ≥50% pain reduction at 600 mg/day 4
- Diabetic neuropathy: NNT 7.8 for ≥50% pain reduction at 600 mg/day 4
- Central neuropathic pain: NNT 9.8 for ≥50% pain reduction at 600 mg/day 4
- Fibromyalgia: NNT 11 for ≥50% pain reduction at 600 mg/day 3
- HIV neuropathy: No evidence of benefit 4
Advantages Over Gabapentin
- Higher bioavailability (>90%, dose-independent) compared to gabapentin's decreasing bioavailability with increasing doses 2
- Faster titration (days vs. weeks) 2
- Lower therapeutic dose (150-600 mg/day vs. 900-3600 mg/day) 2
- Shorter time to steady state (24-48 hours vs. 1-2 days) 2
Common Adverse Effects
- Dizziness: 27-46% at 600 mg/day 5
- Somnolence: 15-25% at 600 mg/day 5
- Weight gain 2
- Peripheral edema, especially in elderly patients 2, 6
- Visual disturbances: Cases of visual field restriction reported in clinical trials 6
Important Precautions
- Not recommended for acute pain management, including postoperative pain 5
- No evidence for use in chronic nociceptive pain like arthritis 5
- Higher rates of adverse events (dizziness, somnolence) in patients ≥65 years 1
- Monitor for neuropsychological reactions, especially in elderly patients 1
- Serious adverse events occur at similar rates to placebo 4
Alternative Options When Pregabalin Is Ineffective
- For neuropathic pain, consider tricyclic antidepressants (first-line) or duloxetine 2, 7
- For fibromyalgia, consider duloxetine or milnacipran as alternatives with similar efficacy 3
Pregabalin provides significant pain relief for a minority of patients with neuropathic pain conditions, with the best response rates seen in postherpetic neuralgia and diabetic neuropathy. Careful dose titration and monitoring for adverse effects are essential for optimizing outcomes.