Should the home dose of pregabalin be held during a stroke workup?

Pregabalin Management During Stroke Workup

Pregabalin should be continued during a stroke workup as there is no evidence supporting its discontinuation, and abrupt cessation could potentially lead to withdrawal symptoms that might complicate neurological assessment. 1, 2

Rationale for Continuing Pregabalin

• Pregabalin is primarily used for neuropathic pain, epilepsy, and anxiety disorders, and does not have direct interactions with standard stroke management protocols 3
• Abrupt discontinuation of pregabalin can lead to withdrawal symptoms including headache, nausea, dizziness, and anxiety, which could complicate neurological assessment during stroke evaluation 2
• Pregabalin has a relatively short half-life of approximately 6.3 hours, making withdrawal symptoms potentially rapid in onset if discontinued 4
• There is no mention in stroke management guidelines about the need to hold pregabalin during stroke workup 1

Considerations During Stroke Workup

• Pregabalin does not affect standard stroke assessment scales such as NIHSS 1
• Pregabalin has minimal hepatic metabolism (<2%) and is primarily excreted unchanged by the kidneys, reducing the risk of drug-drug interactions with acute stroke medications 4
• Some research even suggests pregabalin may have neuroprotective effects in experimental stroke models by suppressing calcium-mediated proteolysis 5

Special Considerations

• For patients with renal impairment (common in stroke patients), dose adjustment may be necessary as pregabalin is primarily excreted by the kidneys 4
• Monitor for potential sedative effects that could impact neurological assessment, particularly at higher doses (≥300 mg/day) 3
• Common side effects of pregabalin include dizziness (13-35%) and somnolence (11-25%), which should be distinguished from stroke symptoms during assessment 3

Medication Management Algorithm

1. Continue pregabalin at the patient's home dose during stroke workup 1, 2
2. Document the patient's pregabalin regimen in the medical record to ensure continuity of care 1
3. Monitor for and document any sedative effects that might impact neurological assessment 3
4. Adjust dose only if renal function is impaired (pregabalin is primarily renally cleared) 4
5. If discontinuation becomes necessary for clinical reasons, implement a gradual tapering schedule rather than abrupt cessation 2

Potential Pitfalls to Avoid

• Abrupt discontinuation of pregabalin can lead to withdrawal symptoms that may confound stroke assessment 2
• Misinterpreting pregabalin side effects (dizziness, somnolence) as stroke symptoms 3
• Failing to consider potential drug interactions with other medications administered during stroke workup, although these are minimal with pregabalin 4

In conclusion, there is no evidence-based reason to hold pregabalin during stroke workup, and discontinuation could potentially complicate assessment due to withdrawal symptoms. Standard stroke management guidelines do not recommend holding pregabalin, and its pharmacokinetic profile suggests minimal risk of interference with stroke evaluation or treatment.