Gabapentin Tapering When Starting Pregabalin
When transitioning from gabapentin to pregabalin, a gradual taper of gabapentin is recommended with a 10-25% reduction of the previous dose every 1-7 days while simultaneously initiating pregabalin therapy. 1
Recommended Tapering Protocol
- Begin with a 10-25% reduction of the previous gabapentin dose every 1-7 days, with slower tapers for patients who have been on higher doses or longer durations of therapy 1
- Simultaneously initiate pregabalin at 50mg three times daily or 75mg twice daily, then increase to 300mg/day after 3-7 days 1
- Further titrate pregabalin by 150mg/day every 3-7 days as needed up to 600mg/day (maximum dose) 1
- Monitor for withdrawal symptoms after each gabapentin dose reduction before proceeding to the next step 1
- For patients on high doses of gabapentin (≥1800mg/day), consider a slower taper of 100mg per month until reaching 300mg, then reduce by 20-30mg per month 2
Cross-Titration Strategy
- Day 1-3: Start pregabalin at initial dose while maintaining full gabapentin dose 1
- Day 4-7: Reduce gabapentin by 10-25% while increasing pregabalin to target dose of 300mg/day 1
- Week 2-3: Continue reducing gabapentin by 10-25% of previous dose every 3-7 days while maintaining pregabalin dose 1
- Week 4+: Complete gabapentin taper while adjusting pregabalin dose for optimal efficacy 1
Managing Withdrawal Symptoms
- Common gabapentin withdrawal symptoms include anxiety, insomnia, nausea, pain, sweating, and in severe cases, akathisia and seizures 3, 4
- If withdrawal symptoms become severe, return to the previous well-tolerated gabapentin dose and slow the taper further 1
- Pregabalin's similar mechanism of action (calcium channel α2-δ ligand) helps mitigate gabapentin withdrawal symptoms during transition 5
- For severe gabapentin dependence, consider much slower tapers (5-10mg decrements every 1-2 weeks for the final 100mg) 2
Special Considerations
- Both medications require dosage reduction in patients with renal insufficiency 1, 6
- Pregabalin has linear pharmacokinetics and more straightforward dosing compared to gabapentin's nonlinear pharmacokinetics 1
- Never abruptly discontinue gabapentin due to risk of withdrawal syndrome, which can occur after as little as 1 month of treatment 3, 4
- Patients who have been on gabapentin for years require much slower tapers than those on short-term therapy 2
Common Pitfalls to Avoid
- Avoid tapering gabapentin too quickly, especially in patients taking high doses (≥3600mg/day) or with long-term use 2, 3
- Don't wait until gabapentin is completely discontinued before starting pregabalin; overlap the medications to minimize withdrawal symptoms 1
- Recognize that both medications can cause dose-dependent dizziness and sedation; start pregabalin at lower doses if these side effects occur 1
- Be aware that complete conversion may take several weeks to months depending on initial gabapentin dose and patient tolerance 2