What are the fall risk considerations when prescribing Lyrica (pregabalin) and Neurontin (gabapentin)?

Fall Risk Associated with Lyrica (Pregabalin) and Neurontin (Gabapentin)

Both pregabalin (Lyrica) and gabapentin (Neurontin) significantly increase fall risk in patients due to their neurological side effects, particularly dizziness and somnolence, and require careful prescribing consideration and patient monitoring.

Mechanism of Fall Risk

• Both medications are associated with significant central nervous system effects that directly contribute to fall risk:
  • Dizziness occurs in approximately 30% of pregabalin-treated patients (vs 8% in placebo) 1
  • Somnolence occurs in approximately 23% of pregabalin-treated patients (vs 8% in placebo) 1
  • Gabapentin similarly causes dizziness (28% vs 8% in placebo) and somnolence (21% vs 5% in placebo) in patients with postherpetic neuralgia 2
  • Both medications can cause ataxia, abnormal gait, and incoordination 2

Risk Factors and Vulnerable Populations

• Fall risk is particularly elevated in:

  • Elderly patients 3, 1
  • Patients with renal impairment (both medications are primarily eliminated through renal excretion) 1, 2
  • Patients taking multiple medications (polypharmacy) 3, 4
  • Patients with pre-existing mobility issues 3

• Risk is significantly higher when starting therapy or increasing doses:

  • New users of benzodiazepines/antipsychotics have an 11.4-fold increased risk of falls 4
  • Similar risk pattern likely applies to gabapentinoids when newly initiated 4

Comparative Risk

• Both medications carry similar fall risks due to their related mechanisms of action 5
• Meta-analyses of psychotropic medications show consistently elevated fall risk:
  • Antidepressants: OR 1.57 (95% CI 1.43-1.74)
  • Benzodiazepines: OR 1.42 (95% CI 1.22-1.65) 6
  • While not directly studied in this meta-analysis, gabapentinoids likely have comparable risk profiles

Risk Mitigation Strategies

• Medication review and modification:

  • Review all medications and consider alternatives when possible 3
  • Particular attention to medication reduction for patients taking four or more medications 3
  • Consider deprescribing or dose reduction in high-risk patients 7

• Dosing considerations:

  • Start with lowest effective dose and titrate slowly 1, 2
  • Use lower doses in elderly or frail patients 1, 2
  • Adjust dose in patients with renal impairment 1, 2
  • Consider divided dosing to minimize peak concentration effects 1

• Patient education and monitoring:

  • Warn patients about potential dizziness and somnolence 1
  • Advise caution with tasks requiring alertness (driving, operating machinery) 1
  • Monitor closely during initiation and dose changes 1, 2
  • Implement fall prevention strategies for high-risk patients 3

Special Considerations

• Co-administration risks:

  • Significantly increased risk when combined with:
    • Opioids (respiratory depression and increased sedation) 1
    • Benzodiazepines (increased sedation) 1
    • Other CNS depressants 1
  • Thiazolidinedione antidiabetic agents can increase peripheral edema risk with pregabalin 1

• Withdrawal considerations:

  • Taper gradually over at least 1 week to minimize withdrawal symptoms 1
  • Abrupt discontinuation may cause insomnia, nausea, headache, anxiety 1

Clinical Approach to Prescribing

1. Before prescribing:

   • Assess baseline fall risk (age, comorbidities, other medications) 3
   • Consider alternatives if fall risk is high 3
   • Review and potentially modify other medications 3

2. When initiating:

   • Start with lowest effective dose 1, 2
   • Educate patient about fall risk and precautions 1
   • Consider home safety assessment for high-risk patients 3

3. During treatment:

   • Monitor for adverse effects, especially during first weeks 1, 2
   • Reassess regularly for continued need and optimal dosing 3
   • Consider deprescribing if falls occur or risk becomes unacceptable 7