What is the recommended dose of pregabalin (lyrica) for treating sciatica?

Pregabalin Dose for Sciatica

Pregabalin is not recommended for sciatica, as the highest quality evidence demonstrates it provides no significant benefit over placebo while causing substantially more adverse effects.

Evidence Against Pregabalin for Sciatica

The most recent and highest quality randomized controlled trial specifically examining pregabalin for sciatica found no efficacy 1:

• At 8 weeks: Mean leg pain scores were 3.7 with pregabalin versus 3.1 with placebo (no significant difference, P=0.19) 1
• At 52 weeks: Mean leg pain scores were 3.4 with pregabalin versus 3.0 with placebo (no significant difference, P=0.46) 1
• No secondary outcomes improved: Disability, back pain intensity, and quality of life measures showed no benefit at either time point 1
• Adverse events were significantly higher: 227 adverse events with pregabalin versus 124 with placebo, with dizziness being particularly problematic 1

This 2017 trial used pregabalin doses of 150 mg/day titrated up to a maximum of 600 mg/day over 8 weeks—the standard dosing approach for neuropathic pain 1.

Limited Evidence for Gabapentinoids in Sciatica

While older guidelines mention gabapentin may have small, short-term benefits in radiculopathy 2, this evidence is weak and predates the definitive negative trial of pregabalin 1. A 2019 head-to-head comparison of gabapentin versus pregabalin in chronic sciatica showed both drugs reduced pain, but gabapentin was superior with fewer adverse events 3:

• Gabapentin: Pain reduction of 1.72 points (P=0.035 versus pregabalin) 3
• Pregabalin: Pain reduction of 0.94 points 3
• Adverse events: 81% with pregabalin versus 19% with gabapentin (P=0.002) 3

However, this study lacked a placebo control, making it impossible to determine if either drug was truly effective 3.

FDA-Approved Indications Do Not Include Sciatica

The FDA label for pregabalin lists approved indications as postherpetic neuralgia, diabetic peripheral neuropathy, fibromyalgia, spinal cord injury neuropathic pain, and partial-onset seizures—but not sciatica or radiculopathy 4. Neither pregabalin nor gabapentin are FDA-approved for low back pain with or without radiculopathy 2.

If Pregabalin Were to Be Used (Not Recommended)

Should a clinician choose to trial pregabalin despite the negative evidence, the FDA-approved dosing for neuropathic pain conditions would be 4:

• Starting dose: 75 mg twice daily (150 mg/day) 4
• Target dose: 150 mg twice daily (300 mg/day) within 1 week 4
• Maximum dose: 300 mg twice daily (600 mg/day) for patients with ongoing pain who tolerate 300 mg/day 4
• Important caveat: Doses above 300 mg/day have higher discontinuation rates due to adverse effects and should be reserved only for those with ongoing pain tolerating lower doses 4

Dose Adjustments

Elderly patients: Lower starting doses (25-50 mg/day) and slower titration are recommended due to increased risk of dizziness, somnolence, and falls 2, 5, 6

Renal impairment: Dose adjustment is mandatory as pregabalin is eliminated primarily by renal excretion 4. Use the Cockcroft-Gault equation to estimate creatinine clearance and adjust accordingly 4.

Common Pitfalls to Avoid

• Do not assume all neuropathic pain responds to pregabalin: Sciatica appears to be a distinct entity that does not respond to gabapentinoids despite their efficacy in other neuropathic conditions 1, 7
• Do not escalate doses hoping for benefit: The 2017 trial showed no benefit even at maximum doses of 600 mg/day 1
• Do not ignore the adverse effect burden: Dizziness, somnolence, and peripheral edema are common and dose-dependent 2, 5
• Do not abruptly discontinue: Taper gradually to avoid withdrawal symptoms 6

Alternative Approach

Given the lack of efficacy, consider evidence-based alternatives for sciatica including physical therapy, spinal manipulation, exercise therapy, or epidural steroid injections rather than pregabalin 2.