Should daily intermittent hemodialysis be done to eliminate Lyrica (pregabalin) in a patient with toxicity?

Management of Pregabalin Toxicity with Hemodialysis

For patients with pregabalin toxicity, intermittent hemodialysis should be performed as the first-line extracorporeal treatment to rapidly eliminate the drug and resolve symptoms.

Rationale for Hemodialysis in Pregabalin Toxicity

• Pregabalin can be effectively removed by hemodialysis, with standard hemodialysis procedures resulting in approximately 50% clearance in 4 hours 1
• Pregabalin has three key properties that make it highly amenable to removal by hemodialysis:
  • Relatively low molecular weight (159.23 Da)
  • Low volume of distribution (0.5 L/kg)
  • Not bound to plasma proteins 2
• Documented hemodialysis clearance rates of 88.8 mL/min have been achieved, which correlates with rapid resolution of toxicity symptoms 2

Recommended Hemodialysis Protocol

• Modality selection: Intermittent hemodialysis is strongly recommended as the preferred extracorporeal treatment modality 3
• Timing: Initiate hemodialysis promptly upon diagnosis of significant pregabalin toxicity 1
• Duration: Continue hemodialysis until clinical improvement is observed 3
• Frequency: Daily intermittent hemodialysis sessions may be required until toxicity resolves 3

Optimizing Hemodialysis Parameters

• Use higher blood flow rates and dialyzers with larger surface area to enhance clearance 3
• Optimize dialysis parameters to reduce risk of hemodynamic compromise:
  • Prime the extracorporeal circuit appropriately
  • Consider lowering dialysate temperature
  • Use dialysate with appropriate electrolyte concentrations
  • Minimize net ultrafiltration if not clinically indicated 3, 4

Monitoring During and After Hemodialysis

• Monitor vital signs and clinical status throughout the procedure 1
• Assess for resolution of toxicity symptoms (reduced consciousness, confusion, agitation, seizures) 1
• Consider serum drug concentration monitoring when available, though clinical improvement should be the primary endpoint 3, 5

When to Stop Hemodialysis

• Base cessation of hemodialysis on clinical improvement rather than predetermined duration 3
• Key indicators for stopping include:
  • Resolution of neurological symptoms
  • Hemodynamic stability
  • Absence of seizure activity 3

Important Considerations

• Administer medications after hemodialysis sessions to avoid premature removal 3, 5
• For patients on chronic hemodialysis who develop pregabalin toxicity, an additional non-scheduled hemodialysis session should be performed 2
• Consult with nephrology for appropriate dialysis prescription and monitoring 3
• Contact a Certified Poison Control Center for up-to-date management recommendations 1

Potential Complications and Mitigation

• Hemodynamic instability during hemodialysis may occur, particularly in critically ill patients 4
• Strategies to mitigate hemodynamic instability include:
  • Cooling the dialysate
  • Adjusting dialysate sodium concentration
  • Careful monitoring of ultrafiltration rates 4
• Electrolyte disturbances may occur during rapid drug removal; monitor and correct as needed 3