What are the uses of Lyrica (pregabalin)?

Uses of Lyrica (Pregabalin)

Pregabalin (Lyrica) is FDA-approved for five specific conditions: management of neuropathic pain associated with diabetic peripheral neuropathy, postherpetic neuralgia, adjunctive therapy for partial-onset seizures in patients 1 month and older, management of fibromyalgia, and management of neuropathic pain associated with spinal cord injury. 1

FDA-Approved Indications

Neuropathic Pain Management

• Diabetic peripheral neuropathy: First-line treatment for painful diabetic neuropathy 2
• Postherpetic neuralgia: Effective for pain following herpes zoster infection 1
• Spinal cord injury pain: Specifically indicated for neuropathic pain from spinal cord trauma 1

Seizure Management

• Partial-onset seizures: Used as adjunctive therapy in patients 1 month of age and older 1

Fibromyalgia

• Effective for managing widespread pain and associated symptoms in fibromyalgia 1

Mechanism of Action

Pregabalin is the pharmacologically active S-enantiomer of racemic 3-isobutyl gamma-aminobutyric acid. While its exact mechanism of action isn't fully understood, it:

• Binds to alpha-2-delta subunits of voltage-gated calcium channels 3
• Reduces calcium influx at nerve terminals
• Decreases the release of several neurotransmitters involved in pain signaling 3
• Does not directly interact with GABA receptors despite structural similarity to GABA 4

Dosing Considerations

• Starting dose:

  • For neuropathic pain: 75 mg BID or 50 mg TID
  • Maximum daily dose: 600 mg 2

• Renal adjustment: Critical as pregabalin is primarily eliminated unchanged through kidneys

  • For CrCl >30-59 mL/min: 200-700 mg/day in divided doses
  • For CrCl 15-30 mL/min: 100-300 mg/day as single daily dose 2

Clinical Efficacy

Pregabalin demonstrates significant efficacy for neuropathic pain conditions:

• For diabetic neuropathy and postherpetic neuralgia, pregabalin at doses of 300 mg, 450 mg, and 600 mg daily (but not at 150 mg) shows meaningful pain reduction 5
• Number needed to treat (NNT) is generally ≤6 for moderate benefit in postherpetic neuralgia and diabetic neuropathy 5
• For fibromyalgia, the NNT is higher at approximately 7 5

Common Adverse Effects

• Most common: Dizziness and somnolence 4
• Other significant effects:
  • Visual disturbances (especially when starting treatment)
  • Peripheral edema
  • Weight gain
  • Potential for cardiac adverse events 2

Special Considerations

Risk of Abuse and Dependence

• Classified as a Schedule V controlled substance due to potential for abuse 4
• Should not be discontinued abruptly; taper over at least one week 2

Precautions

• Pregnancy: Contraindicated in pregnant women or those who may become pregnant without reliable contraception 2
• Substance use disorders: Patients with history require close monitoring 2
• Elderly patients: Higher risk of adverse effects; consider lower starting doses 2

Treatment Guidelines Position

For neuropathic pain management, pregabalin is considered a first-line agent along with:

• Gabapentin (similar mechanism but different pharmacokinetics) 5
• Duloxetine and other SNRIs 5
• Tricyclic antidepressants 5

For fibromyalgia, pregabalin is one of several effective options, with duloxetine and milnacipran also showing efficacy 5

Emerging Uses

While not FDA-approved for these indications, research suggests potential benefit in:

• Generalized anxiety disorder 6, 7
• Social anxiety disorder 8
• Acute pain management 8

By understanding pregabalin's approved uses and mechanism of action, clinicians can appropriately select this medication for patients with neuropathic pain conditions, seizure disorders, or fibromyalgia while monitoring for potential adverse effects.