Maximum Dose of Lyrica (Pregabalin)
The maximum recommended dose of pregabalin is 600 mg per day, administered in two or three divided doses. 1
FDA-Approved Maximum Dosing
The FDA label clearly establishes 600 mg/day as the ceiling dose across all approved indications 1:
- Postherpetic neuralgia: Maximum 600 mg/day (300 mg twice daily or 200 mg three times daily) 1
- Diabetic peripheral neuropathy: Maximum 300 mg/day (100 mg three times daily), as doses above this provide no additional benefit and are less well tolerated 1
- Partial-onset seizures (adults): Maximum 600 mg/day 1
- Fibromyalgia: Maximum 450 mg/day (though the absolute ceiling remains 600 mg/day) 1
Clinical Context for Maximum Dosing
Doses above 300 mg/day should be reserved only for patients with ongoing pain who tolerate the 300 mg/day dose well and have not achieved adequate relief. 2, 3, 1
Key Dosing Principles:
- Standard therapeutic dose: 300 mg/day is considered the moderate dose that provides optimal benefit-to-risk ratio for most neuropathic pain conditions 3
- Higher doses often don't provide additional benefits but significantly increase side effects 3, 1
- Dose-dependent adverse effects include dizziness (23-46%), somnolence (15-25%), and peripheral edema (10%) 3
Titration to Maximum Dose
When escalating to maximum doses 3, 1:
- Start at 150 mg/day (75 mg twice daily or 50 mg three times daily) 3, 1
- Increase to 300 mg/day within 1 week based on efficacy and tolerability 3, 1
- For inadequate pain relief after 2-4 weeks on 300 mg/day, may increase to 600 mg/day only if patient tolerates current dose well 3, 1
- Titrate gradually with weekly increments to minimize side effects 3
Critical Dosing Adjustments
Renal impairment mandates dose reduction as pregabalin is eliminated primarily by renal excretion 2, 3, 1:
- CrCl 30-60 mL/min: Reduce total daily dose by approximately 50% 3
- CrCl 15-30 mL/min: Reduce total daily dose by 75% 3
- CrCl <15 mL/min: Reduce total daily dose by 85-90% 3
Elderly patients require lower starting doses and slower titration due to increased risk of dizziness, somnolence, confusion, and falls 3
Important Safety Considerations
- Taper gradually over minimum 1 week when discontinuing to avoid withdrawal symptoms 3, 1
- Monitor for emergence or worsening of depression and suicidal thoughts 4
- Weight gain and peripheral edema are dose-related, particularly in elderly patients 5, 4
- Avoid rapid IV administration or combination with other CNS depressants which increases risk of respiratory depression and sedation 4