How do I safely discontinue gabapentin (Neurontin) and start Lyrica (pregabalin)?

How to Safely Transition from Gabapentin to Pregabalin

Taper gabapentin gradually over 1-7 days with 10-25% dose reductions while simultaneously starting pregabalin at 50 mg three times daily or 75 mg twice daily, monitoring closely for withdrawal symptoms after each gabapentin reduction. 1

Recommended Cross-Titration Protocol

The optimal approach is a cross-titration strategy rather than abrupt discontinuation:

• Start pregabalin at 50 mg three times daily or 75 mg twice daily (150 mg/day total) while maintaining your current gabapentin dose 1, 2
• After 3-7 days, begin reducing gabapentin by 10-25% of the previous dose every 1-7 days 1
• Simultaneously increase pregabalin to 300 mg/day (100 mg three times daily or 150 mg twice daily) after the first 3-7 days 1, 2
• Continue tapering gabapentin completely off while maintaining pregabalin at 300 mg/day 1

The FDA label confirms that gabapentin discontinuation should occur gradually over a minimum of 1 week 3, and pregabalin should also be tapered over a minimum of 1 week when discontinuing 2.

Critical Monitoring Requirements

Monitor for withdrawal symptoms after each gabapentin dose reduction before proceeding to the next taper step 1:

• Anxiety, agitation, and restlessness 4, 5, 6
• Diaphoresis and palpitations 6
• Flu-like symptoms (particularly in elderly patients) 4
• Mental status changes 4, 5
• In severe cases: seizures or status epilepticus (especially with abrupt discontinuation from high doses) 7, 6

If withdrawal symptoms become severe, return to the previous well-tolerated gabapentin dose and slow the taper further 1.

Renal Function Assessment (Non-Negotiable)

Calculate creatinine clearance using the Cockcroft-Gault equation before initiating pregabalin, as both medications are renally excreted 8, 1:

• For creatinine clearance 30-60 mL/min: reduce pregabalin total daily dose by approximately 50% 9
• For creatinine clearance 15-30 mL/min: reduce by 75% 9
• For creatinine clearance <15 mL/min: reduce by 85-90% 9

The FDA label specifies that pregabalin dosing must be adjusted in patients with reduced renal function 2, and gabapentin requires similar adjustments 3.

Pregabalin Titration After Transition

Once gabapentin is fully discontinued and the patient is stable on pregabalin 300 mg/day:

• Allow 2-4 weeks at 300 mg/day to assess efficacy 2
• If inadequate pain relief and the medication is well-tolerated, increase by 150 mg/day every 3-7 days up to a maximum of 600 mg/day 1, 2
• Reserve doses above 300 mg/day only for patients with ongoing pain who tolerate the 300 mg/day dose, as higher doses increase adverse effects without proportional benefit 2

Alternative Approach: Immediate Discontinuation

Pharmacokinetic modeling suggests immediate discontinuation of gabapentin with same-day initiation of pregabalin is theoretically feasible 10, but this approach carries higher risk:

• Predicted pregabalin-equivalent concentrations remain stable within 1 day of transition 10
• However, clinical case reports demonstrate significant withdrawal symptoms can occur 12 hours to 7 days after gabapentin discontinuation 6
• This approach is NOT recommended given the documented risk of severe withdrawal, including seizures 7, 6

Common Pitfalls to Avoid

• Never abruptly discontinue gabapentin, especially from doses >3000 mg/day—this can precipitate status epilepticus 7, 6
• Do not taper too quickly—withdrawal symptoms have been reported even with 1-week tapers in elderly patients 4
• Do not assume pregabalin will have fewer side effects—both medications cause dizziness (19-46%), somnolence (14-25%), and peripheral edema at similar rates 9
• Do not fail to assess renal function before initiating pregabalin—this is mandatory 9, 2
• Do not start pregabalin at high doses—begin at 150 mg/day and titrate gradually to minimize adverse effects 9, 2

Special Considerations for Elderly Patients

Lower starting doses and slower titration are specifically recommended in geriatric patients 8, 9:

• Elderly patients are more susceptible to dizziness, confusion, sedation, and falls 9
• A 76-year-old patient developed severe akathisia after only 4 days without gabapentin despite taking it for just 1 month 5
• An 81-year-old patient developed debilitating withdrawal symptoms after a 1-week taper following 5 years of gabapentin use 4

Timeline Expectations

Allow adequate time for the complete transition:

• Minimum 1-2 weeks for the gabapentin taper and pregabalin initiation 1, 3
• Additional 2-4 weeks at pregabalin 300 mg/day to assess efficacy 2
• Total transition period: 3-6 weeks minimum 1, 2