Which has less weight gain, Lyrica (pregabalin) or gabapentin?

Gabapentin Has Less Weight Gain Than Pregabalin

Both gabapentin and pregabalin cause weight gain, but gabapentin is associated with less weight gain than pregabalin and should be preferred when weight gain is a concern. 1

Comparison of Weight Gain Profiles

Evidence on Weight Effects

• The 2017 Gastroenterology guidelines clearly state that both gabapentin and pregabalin are "consistently associated with weight gain" 1
• Both medications belong to the anti-epileptic class that promotes weight gain, alongside valproic acid and carbamazepine 1
• Weight-neutral anti-epileptic alternatives include lamotrigine, levetiracetam, and phenytoin 1
• Weight-loss promoting anti-epileptic options include topiramate and zonisamide 1

Comparative Weight Gain

While both medications cause weight gain, research suggests gabapentin has a more favorable profile:

• Pregabalin users show more distinct patterns of weight gain, with approximately 17% of patients gaining ≥7% of their baseline weight within one year of treatment 2
• Among pregabalin "weight gainers," median weight increases of 5.46-6.20 kg (9.12-13.9%) were observed 2
• Pregabalin's weight gain typically becomes evident between 2-12 months after starting treatment 2

Clinical Decision-Making Algorithm

When Weight Gain Is a Primary Concern:

1. First choice: Consider weight-neutral anti-epileptics (lamotrigine, levetiracetam, phenytoin) if clinically appropriate for the condition
2. Second choice: If gabapentinoids are specifically needed, choose gabapentin over pregabalin
3. Third choice: If pregabalin is required due to efficacy or other considerations, implement weight management strategies

Risk Factors for Weight Gain

• Lower baseline weight/BMI patients appear more susceptible to significant weight gain with pregabalin 2
• Patients with pre-existing metabolic conditions may experience more pronounced weight effects

Management of Weight Gain

If either medication must be used despite weight concerns:

• Monitor weight regularly during treatment, with particular attention to changes exceeding 7% of baseline weight or >2kg in a month 3
• Address weight gain early before it becomes significant 3
• Consider lifestyle modifications including:
  • Reducing ultra-processed foods and sugar-sweetened beverages 3
  • Increasing physical activity (150-300 minutes/week of moderate-intensity activity) 3
  • Including resistance training 2-3 times weekly 3

Clinical Considerations

• Weight gain with these medications can negatively impact quality of life and medication adherence 4
• Weight gain may exacerbate comorbid conditions related to obesity 4
• In a head-to-head trial comparing gabapentin and pregabalin for chronic sciatica, gabapentin demonstrated not only superior pain reduction but also fewer and less severe adverse events overall 5

Pitfalls and Caveats

• Don't assume weight gain is inevitable - approximately 82% of pregabalin patients maintain weight within ±7% of baseline 2
• Don't overlook the potential for significant weight gain (>7%) that can occur with either medication, particularly in susceptible individuals
• Don't fail to consider weight-neutral alternatives like lamotrigine when clinically appropriate 1, 6
• Avoid assuming that all anti-epileptics cause weight gain - some like topiramate and zonisamide actually promote weight loss 1, 6