Pregabalin Dosing for Diabetic Neuropathy
The recommended dosage of pregabalin for diabetic peripheral neuropathy is 50 mg three times a day (150 mg/day) initially, which may be increased to a maximum of 100 mg three times a day (300 mg/day) within 1 week based on efficacy and tolerability. 1
Initial Dosing and Titration
- Begin with 50 mg three times a day (150 mg/day) in patients with normal renal function (creatinine clearance ≥60 mL/min) 1
- The dose may be increased to 300 mg/day within 1 week based on efficacy and tolerability 1
- Pregabalin can be taken orally with or without food 1
- For elderly patients, consider starting at a lower dose (25-50 mg/day) due to increased risk of side effects 2
Maximum Recommended Dose
- The maximum recommended dose is 100 mg three times a day (300 mg/day) 1
- Although pregabalin was studied at 600 mg/day, there is no evidence that this dose provides additional significant benefit and it was less well tolerated 1
- In view of dose-dependent adverse reactions, treatment with doses above 300 mg/day is not recommended 1
Efficacy Assessment
- Evaluate pain reduction after 2-4 weeks of treatment 3
- Consider treatment successful if pain is reduced by ≥30% from baseline 3
- Clinical trials show a Number Needed to Treat (NNT) of 5.99 for 300 mg/day in painful diabetic neuropathy 3
Renal Dose Adjustment
- Because pregabalin is eliminated primarily by renal excretion, adjust the dose in patients with reduced renal function 1
- 98% of the drug is eliminated through renal excretion 4
Discontinuation
- When discontinuing pregabalin, taper gradually over a minimum of 1 week to minimize withdrawal symptoms 1
Common Side Effects
- Dizziness is the most common side effect (23.1%) 4
- Other common side effects include drowsiness (14.6%) and peripheral edema (10.4%) 4
- Side effects are generally mild to moderate and dose-dependent 4
- Side effects can often be managed by dose reduction without discontinuing therapy 4
Alternative Treatments if Pregabalin is Ineffective
- Gabapentin (starting with 100-300 mg at bedtime or 100-300 mg three times daily, maximum 3600 mg/day) 3
- Duloxetine (60-120 mg/day) with an NNT of 5.2 for 60 mg/day and 4.9 for 120 mg/day 3
- Tricyclic antidepressants (starting at 10 mg/day, increasing to 75 mg/day) have an NNT of 1.5-3.5 but should be used cautiously in patients with cardiovascular disease 2
Clinical Pearls
- Pregabalin shows significant pain reduction as early as the first week of treatment 5
- The most commonly preferred effective dose in clinical practice is 150 mg twice daily 6
- Pregabalin has been shown to improve not only pain but also sleep interference in patients with diabetic neuropathy 7, 5
- Pregabalin has a better side effect profile compared to amitriptyline, with fewer reports of drowsiness 6