Maximum Dose of Pregabalin for Neuropathy
The maximum recommended dose of pregabalin for neuropathy is 600 mg per day, divided into two or three doses. 1
FDA-Approved Dosing by Neuropathy Type
Diabetic Peripheral Neuropathy
- Maximum dose: 300 mg/day (100 mg three times daily) 1
- Start at 50 mg three times daily (150 mg/day) 1
- May increase to 300 mg/day within 1 week based on efficacy and tolerability 1
- Important caveat: Although pregabalin was studied at 600 mg/day for diabetic neuropathy, there is no evidence this dose provides additional benefit and it was less well tolerated 1
- Treatment with doses above 300 mg/day is not recommended for diabetic neuropathy due to dose-dependent adverse reactions 1
Postherpetic Neuralgia
- Maximum dose: 600 mg/day (300 mg twice daily or 200 mg three times daily) 1
- Start at 75 mg twice daily or 50 mg three times daily (150 mg/day) 1
- Increase to 300 mg/day within 1 week 1
- For patients with inadequate pain relief after 2-4 weeks on 300 mg/day who tolerate the medication well, may increase to 600 mg/day 1
- Reserve doses above 300 mg/day only for patients with ongoing pain who are tolerating 300 mg/day, due to higher discontinuation rates from adverse effects 1
Spinal Cord Injury-Related Neuropathic Pain
- Maximum dose: 600 mg/day (300 mg twice daily) 1, 2
- Start at 75 mg twice daily (150 mg/day) 1
- Increase to 300 mg/day within 1 week 1
- For insufficient relief after 2-3 weeks on 300 mg/day, may increase to 600 mg/day 1, 2
Key Clinical Considerations
Dosing Strategy
- Pregabalin has linear pharmacokinetics, making dosing more predictable than gabapentin 3
- Most patients achieve noticeable effects within 1 week, with median onset of pain relief at 1.5-3.5 days 3, 4
- Allow 4 weeks at therapeutic dose for an adequate trial 3
Renal Impairment
- Mandatory dose reduction required in patients with reduced renal function, as pregabalin is eliminated 98% by renal excretion 1, 5
- Adjust based on creatinine clearance: reduce total daily dose by approximately 50% for CLcr 30-60 mL/min, 75% for CLcr 15-30 mL/min, and 85-90% for CLcr <15 mL/min 3
Elderly Patients
- Consider lower starting doses and slower titration due to increased risk of dizziness, somnolence, confusion, and falls 3
Common Adverse Effects
- Dizziness (23-46%), somnolence (15-25%), peripheral edema (10%), dry mouth, and constipation 3, 5, 6
- Side effects are dose-dependent and typically manifest within the first 2 weeks 2, 5
- Can be managed with dose reduction without discontinuing therapy 5
Discontinuation
Critical Safety Warning
- Serious breathing problems can occur when combined with opioids, benzodiazepines, or other CNS depressants 3