What is the recommended dose of pregabalin (Lyrica) for various conditions?

Pregabalin Dosing Recommendations

Starting Dose and Titration

Start pregabalin at 75 mg twice daily or 50 mg three times daily (150 mg/day total), then titrate based on the specific condition being treated. 1

Initial Dosing Strategy

• Begin with 75 mg at bedtime or 50 mg three times daily, with gradual weekly increases to the effective dose 2
• Administer in 2-3 divided doses per day 2
• The medication can be taken with or without food 1

Condition-Specific Dosing

Diabetic Peripheral Neuropathy

• Start at 50 mg three times daily (150 mg/day) 1
• Maximum recommended dose is 300 mg/day (100 mg three times daily) 1
• Increase to 300 mg/day within 1 week based on efficacy and tolerability 1
• Doses above 300 mg/day are NOT recommended for this condition, as 600 mg/day showed no additional benefit and was less well tolerated 1

Postherpetic Neuralgia

• Start at 75 mg twice daily or 50 mg three times daily (150 mg/day) 1
• Standard effective dose is 300 mg/day (150 mg twice daily or 100 mg three times daily) 2, 3
• May increase to 300 mg/day within 1 week 1
• Reserve doses above 300 mg/day (up to maximum 600 mg/day) ONLY for patients with ongoing pain who tolerate 300 mg/day after 2-4 weeks of treatment 2, 1

Neuropathic Pain (General)

• Start at 50 mg three times daily or 75 mg twice daily 3
• Increase to 300 mg/day after 3-7 days if needed 3
• Further increase by 150 mg/day every 3-7 days up to maximum 600 mg/day if pain relief is insufficient 3
• Allow 4 weeks to fully assess efficacy before determining treatment failure 3
• Noticeable effects may occur within 1 week 3, 4

Partial-Onset Seizures (Adjunctive Therapy)

• Adults: Start at 150 mg/day, maximum 600 mg/day in 2-3 divided doses 1
• Pediatric patients ≥30 kg: Start at 2.5 mg/kg/day, maximum 10 mg/kg/day (not exceeding 600 mg/day) 1
• Pediatric patients <30 kg: Start at 3.5 mg/kg/day, maximum 14 mg/kg/day 1

Fibromyalgia

• Start at 75 mg twice daily (150 mg/day) 1
• Recommended dose range is 300-450 mg/day 1
• Increase to 150 mg twice daily (300 mg/day) within 1 week based on response 1

Maximum Dosing

The absolute maximum dose of pregabalin is 600 mg/day in divided doses for any indication 2, 1. However, this maximum should be reserved for specific situations:

• Higher doses (>300 mg/day) often provide no additional benefit but increase side effects 2
• The dose-response relationship is dose-dependent, with better efficacy at higher doses but also more adverse effects 1, 5

Special Populations

Elderly Patients

• Use lower starting doses and slower titration due to increased risk of dizziness, somnolence, confusion, and falls 2, 4
• Side effects are more pronounced in elderly patients 2

Renal Impairment

• Dose adjustment is REQUIRED as pregabalin is 98% renally excreted unchanged 2, 4, 5
• Reduce doses in patients with creatinine clearance <60 mL/min 1

Switching from Gabapentin

When transitioning from gabapentin, start pregabalin at 75 mg twice daily while continuing morning gabapentin for the first few days, then gradually taper gabapentin over several days to weeks 2, 4. Alternative starting dose is 50 mg three times daily 2, 4.

Key Differences

• Pregabalin has more predictable absorption and linear pharmacokinetics compared to gabapentin 2
• Pregabalin may show effects within 1 week versus 2+ months for gabapentin 4
• Maximum gabapentin dose is 3600 mg/day versus 600 mg/day for pregabalin 2

Discontinuation

Taper pregabalin gradually over a minimum of 1 week to avoid withdrawal symptoms 1.

Common Side Effects (Dose-Dependent)

• Dizziness: 23-46% 2, 5
• Somnolence: 15-25% 2, 5
• Peripheral edema: 10% 2, 5
• Dry mouth and constipation 2
• Weight gain 2

These side effects are manageable with dose reduction and do not necessarily require discontinuation 5. Start with lower doses and implement slow escalation to minimize peak-related side effects 2.

Clinical Pearls

• Pregabalin requires NO hepatic metabolism and has NO cytochrome P-450 interactions, making drug interactions minimal 6
• Pregabalin is a Schedule V controlled substance due to potential for abuse and dependence 6
• Treatment discontinuation due to adverse events occurs in 18-28% of patients at 600 mg/day 7
• Only a minority of patients achieve substantial benefit; individualization is essential to maximize relief while minimizing adverse effects 7