What are the effects of Lyrica (pregabalin) on mental status in hospitalized patients with impaired renal function undergoing dialysis?

Effects of Pregabalin (Lyrica) on Mental Status in Hospitalized Dialysis Patients

Pregabalin should be used with extreme caution in hospitalized dialysis patients due to significantly increased risk of altered mental status, even at lower doses, and requires substantial dose reduction with close monitoring. 1, 2

Pharmacokinetics and Dosing in Dialysis Patients

• Pregabalin is primarily eliminated by renal excretion as unchanged drug, making patients with impaired renal function at high risk for toxicity 1
• Approximately 50% of pregabalin is removed during a 4-hour hemodialysis session, requiring careful dose timing and adjustment 1
• For dialysis patients, dosage must be significantly reduced compared to patients with normal renal function 1, 3
• The FDA recommends dose adjustment based on creatinine clearance, with supplemental doses potentially required after hemodialysis sessions 1, 3

Mental Status Effects in Dialysis Patients

• Gabapentinoids (pregabalin and gabapentin) are associated with a 51% higher hazard of altered mental status in hemodialysis patients, even at lower doses 2

• Common mental status changes include:

  • Somnolence and sedation 4
  • Confusion and disorientation 2
  • Dizziness 4
  • Cognitive impairment 2

• These adverse effects occur in a dose-dependent manner, with higher risk at increased doses 2

• Even at lower doses (≤100 mg daily), pregabalin is associated with significant risk of altered mental status in dialysis patients 2

Additional Safety Concerns

• Pregabalin use in dialysis patients is associated with:

  • 68% higher hazard of falls 2
  • Increased risk of fractures 2
  • Potential for drug interactions with other CNS depressants commonly used in hospitalized patients 5

• Hospitalized patients may be particularly vulnerable due to:

  • Acute illness affecting drug metabolism 5
  • Concomitant medications that may interact with pregabalin 5
  • Changes in fluid status affecting drug concentration 3

Practical Management Recommendations

• Initial dosing should start at 25 mg daily (not the standard starting dose used in patients with normal renal function) 4
• Titrate slowly based on response and tolerability, generally not exceeding 50-75 mg daily in most dialysis patients 4
• Administer pregabalin after hemodialysis on dialysis days 1, 3
• Monitor mental status closely, especially after initial dosing and dose increases 2
• Consider alternative non-pharmacological approaches for pain management in dialysis patients, such as:
  • Music therapy, which has shown benefits for anxiety and pain perception 6
  • Physical activity appropriate to patient ability 5
  • Cognitive behavioral therapy 5

Medication Reconciliation and Review

• Perform thorough medication reconciliation to identify potential drug interactions with pregabalin 5

• Be particularly cautious with concomitant use of:

  • Opioid analgesics, which carry their own risks of altered mental status in dialysis patients 7
  • Other CNS depressants (benzodiazepines, antihistamines) 5
  • Antidepressants, which may have variable effects in dialysis patients 5

• Regular medication review by clinical pharmacists can reduce hospitalization rates in dialysis patients 5

Common Pitfalls to Avoid

• Using standard pregabalin dosing without renal adjustment 1, 3
• Failing to recognize early signs of CNS toxicity 2
• Not timing doses appropriately in relation to dialysis sessions 1, 3
• Overlooking non-pharmacological alternatives for symptom management 5, 6
• Inadequate monitoring of mental status changes in hospitalized dialysis patients receiving pregabalin 2