What are the management options for dizziness caused by Pregabalin (Lyrica)?

Management of Pregabalin-Induced Dizziness

Dizziness from pregabalin is dose-dependent and occurs in 30% of patients; the primary management strategy is dose reduction or slower titration, as dizziness typically begins shortly after initiation and occurs more frequently at higher doses. 1

Understanding the Problem

Incidence and Timing:

• Dizziness affects 30% of pregabalin-treated patients versus 8% on placebo 1
• Onset occurs shortly after initiating therapy and is dose-dependent 1
• In 30% of affected patients, dizziness persists until the last dose of treatment 1
• Dizziness is one of the two most common reasons for treatment discontinuation (4% withdrawal rate) 1

Primary Management Strategies

1. Dose Reduction (First-Line Approach)

Immediately reduce the current dose if dizziness is intolerable. 2, 1

• The FDA label explicitly states that dizziness and somnolence are dose-dependent and can be managed by dose reduction without discontinuing therapy 2
• Most patients achieve optimal benefit at 300 mg/day; doses above this increase side effects without consistently improving efficacy 2

2. Slower Titration Protocol

Start at the lowest possible dose and increase gradually: 2

• Begin with 75 mg at bedtime or 50 mg three times daily (150 mg/day total) 2
• Increase to 300 mg/day over one week only if tolerated 2
• For elderly patients or those with renal impairment, use even lower starting doses and slower titration 3, 2

3. Timing Optimization

Administer the medication at bedtime to minimize daytime functional impairment from dizziness. 2

• Consider divided dosing (2-3 times daily) to minimize peak-related side effects 2

High-Risk Populations Requiring Extra Caution

Elderly Patients (≥65 years)

Age ≥65 years is an independent risk factor for dizziness (adjusted odds ratio: 2.507). 4

• Use lower starting doses (consider 25-50 mg at bedtime initially) 3, 2
• Implement slower titration with longer intervals between dose increases 3, 2
• Elderly patients are at increased risk for falls, confusion, and sedation 3

Patients on Concomitant CNS Depressants

Co-administration of opioids increases the risk of dizziness and somnolence by 5.5-fold (adjusted odds ratio: 5.507). 5, 4

• Among patients regularly receiving strong opioids, 50% experienced somnolence or dizziness versus 14.9% without opioids 4
• When combining pregabalin with opioids or benzodiazepines, start at the lowest possible dose and monitor closely 1
• Avoid alcohol consumption, as pregabalin potentiates impairment of motor skills and sedating effects 1

Patients with Renal Impairment

Dose adjustment is mandatory in renal dysfunction, as pregabalin is 95% renally excreted. 2

• Reduce total daily dose by approximately 50% for CrCl 30-60 mL/min 2
• Reduce by 75% for CrCl 15-30 mL/min 2
• Reduce by 85-90% for CrCl <15 mL/min 2

Perioperative Context (Special Consideration)

For perioperative use, limit pregabalin to a single lowest preoperative dose to minimize sedation, dizziness, and visual disturbances. 3

• Meta-analyses show that while pregabalin reduces postoperative pain and opioid consumption, these benefits are offset by increased sedation, dizziness, and visual disturbances 3
• Gabapentinoids should preferably be limited to a single lowest dose unless indicated for postoperative neuropathic pain 3

Critical Safety Warnings

Counsel patients that dizziness may impair their ability to drive or operate machinery. 1

• Advise patients not to drive, operate complex machinery, or engage in hazardous activities until they gauge how pregabalin affects them 1
• Warn about increased fall risk, especially in elderly patients 3, 2

When to Consider Discontinuation

If dizziness remains intolerable despite dose reduction, taper pregabalin gradually over a minimum of 1 week. 1

• Abrupt discontinuation can cause withdrawal symptoms including insomnia, nausea, headache, anxiety, and increased seizure frequency in patients with seizure disorders 1
• Do not discontinue abruptly 1

Alternative Considerations

Switching from pregabalin to gabapentin will not necessarily reduce dizziness, as both medications have nearly identical adverse effect profiles. 2

• Both cause dizziness, somnolence, and visual disturbances at comparable rates 2
• If one gabapentinoid causes intolerable dizziness, the other likely will as well 2