Pregabalin Dosing for Peripheral Neuropathy
For peripheral neuropathy, pregabalin should be started at 50 mg three times daily (150 mg/day) and titrated up to 300 mg/day within one week based on efficacy and tolerability. 1
Initial Dosing and Titration
- Starting dose: 50 mg three times daily (150 mg/day) or 75 mg twice daily 2, 1
- Titration: Increase to 300 mg/day within 1 week based on efficacy and tolerability 1
- Maximum recommended dose: 300 mg/day for diabetic peripheral neuropathy 1
- Dosing frequency: Divided into 2-3 doses per day 2, 1
Specific Neuropathy Types
Diabetic Peripheral Neuropathy
- Maximum recommended dose is 300 mg/day 1
- Although pregabalin was studied at 600 mg/day, there is no evidence of additional significant benefit at this higher dose, and it was less well tolerated 1
- Duration of adequate trial: 4 weeks 2
Postherpetic Neuralgia
- Recommended dose: 75-150 mg twice daily or 50-100 mg three times daily (150-300 mg/day) 1
- For patients not experiencing sufficient pain relief after 2-4 weeks at 300 mg/day, dosage may be increased up to 600 mg/day (300 mg twice daily or 200 mg three times daily) 1
- Higher doses (>300 mg/day) should be reserved only for patients with ongoing pain who are tolerating 300 mg/day 1
Dosing Considerations
Renal Impairment
- Dose adjustment required in patients with reduced renal function 2, 3, 1
- Pregabalin is eliminated primarily by renal excretion (98%) 4
Elderly Patients
- Consider lower starting dosages and slower titration 3
Discontinuation
- When discontinuing pregabalin, taper gradually over a minimum of 1 week to avoid withdrawal symptoms 1
Advantages of Pregabalin
- Linear pharmacokinetics make dosing more straightforward compared to gabapentin 2
- May provide analgesia more quickly than gabapentin as the initial dosage of 150 mg/day has been found efficacious in some trials 2
- Efficacy can be noted within the first several days of administration 5
Common Side Effects
- Most common adverse effects: dizziness (23.1%), somnolence/drowsiness (14.6%), and peripheral edema (10.4%) 4
- Side effects are dose-dependent and typically mild to moderate 4
- Side effects typically manifest within the first 2 weeks of treatment 5
- Side effects can often be managed with dose reduction without discontinuing therapy 4
Efficacy Evidence
- Clinical trials have demonstrated significant pain reduction with pregabalin 600 mg/day compared to placebo in diabetic peripheral neuropathy 6, 7
- Pregabalin significantly reduces sleep interference and improves sensory and affective pain scores 6
- In the US, pregabalin is a Schedule V drug due to potential for abuse and dependence 2, 8
Comparative Considerations
- Pregabalin has similar efficacy and tolerability to gabapentin but with more straightforward dosing due to linear pharmacokinetics 2
- Pregabalin is one of the first-line treatments for neuropathic pain along with gabapentin, tricyclic antidepressants, and SNRIs like duloxetine 3
Remember that pregabalin can be taken with or without food, and the dose should be adjusted based on patient response and tolerability.