Pregabalin (Lyrica) Dosage and Usage Guidelines
Pregabalin should be started at 50 mg three times daily or 75 mg twice daily and titrated up to a maximum of 600 mg daily divided into 2-3 doses, with specific dosing regimens varying by indication. 1, 2
General Dosing Principles
- Pregabalin is administered orally with or without food in 2-3 divided doses daily 1
- When discontinuing pregabalin, taper gradually over a minimum of 1 week to minimize withdrawal symptoms 1
- Dose adjustment is required for patients with renal impairment as pregabalin is primarily excreted unchanged by the kidneys 2, 1
Indication-Specific Dosing
Neuropathic Pain Associated with Diabetic Peripheral Neuropathy
- Initial dose: 50 mg three times daily (150 mg/day) 1
- Maximum recommended dose: 100 mg three times daily (300 mg/day) 1
- May increase to maximum dose within 1 week based on efficacy and tolerability 1
- Although studied at 600 mg/day, no evidence of additional benefit at this dose and more adverse effects 1
Postherpetic Neuralgia
- Initial dose: 75 mg twice daily or 50 mg three times daily (150 mg/day) 1
- Recommended dose range: 150-300 mg/day 1
- May increase to 300 mg/day within 1 week based on efficacy and tolerability 1
- For insufficient pain relief after 2-4 weeks at 300 mg/day, may increase to 600 mg/day (300 mg twice daily or 200 mg three times daily) if tolerated 1
Fibromyalgia
- Initial dose: 75 mg twice daily (150 mg/day) 1
- Recommended dose range: 300-450 mg/day 1
- May increase to 300 mg/day within 1 week, and further to 450 mg/day if needed 1
- Doses above 450 mg/day not recommended due to increased adverse effects 1
Neuropathic Pain Associated with Spinal Cord Injury
- Initial dose: 75 mg twice daily (150 mg/day) 1
- Recommended dose range: 150-600 mg/day 1
- May increase to 300 mg/day within 1 week based on efficacy and tolerability 1
- For insufficient pain relief after 2-3 weeks at 300 mg/day, may increase to 600 mg/day if tolerated 1
Adjunctive Therapy for Partial-Onset Seizures
- Adults: Initial dose of 150 mg/day, maximum dose of 600 mg/day, divided into 2-3 doses 1
- Pediatric patients ≥30 kg: 2.5 mg/kg/day initially, maximum 10 mg/kg/day (not exceeding 600 mg/day) 1
- Pediatric patients <30 kg: 3.5 mg/kg/day initially, maximum 14 mg/kg/day 1
Special Populations
Elderly Patients
- Consider lower starting doses and slower titration due to increased risk of adverse effects 2
- Common side effects in elderly include dizziness, somnolence, and confusion 2
Patients with Renal Impairment
- Dose adjustment required based on creatinine clearance 1
- Supplemental dose recommended immediately following hemodialysis 1
Common Side Effects
- Dizziness (23-46%), somnolence (15-25%), and peripheral edema (10%) 2, 3
- Other common side effects include ataxia, diplopia, and weight gain 3, 4
- Side effects are generally dose-dependent and manageable with dose reduction 2, 5
Pharmacokinetic Advantages
- Rapid and almost complete absorption 4
- Lack of protein binding and linear kinetics 4
- Absence of enzyme induction and drug interactions 4
- More predictable absorption and linear pharmacokinetics compared to gabapentin 2
Clinical Pearls
- Pregabalin is more efficiently absorbed through the GI tract than gabapentin 6
- The maximum dose of gabapentin is 3600 mg/day compared to 600 mg/day for pregabalin 2
- Both efficacy and adverse event profiles are dose-related 1
- The effect of dose escalation rate on tolerability has not been formally studied 1