How do you manage pregabalin (Lyrica) perioperatively?

From the Guidelines

Lyrica (pregabalin) should generally be continued perioperatively without interruption. For patients already on Lyrica, administer their usual dose on the morning of surgery with a sip of water. If oral administration is not possible postoperatively, consider using gabapentin as a temporary substitute at a 1:6 ratio (100 mg pregabalin equals approximately 600 mg gabapentin) 1. Resume the patient's regular Lyrica regimen once oral intake is established. For opioid-tolerant patients or those with neuropathic pain, initiating Lyrica preoperatively (150-300 mg daily in divided doses, starting 1-5 days before surgery) may be beneficial as part of a multimodal pain management strategy.

Some key considerations when managing Lyrica perioperatively include:

• Monitoring for side effects such as dizziness and somnolence, which may be additive with other perioperative medications 1
• Avoiding abrupt discontinuation, which can cause withdrawal symptoms including insomnia, nausea, headache, or diarrhea
• Adjusting the dose in patients with renal impairment (reduce by 50% if CrCl is 30-60 mL/min and by 75% if CrCl is 15-30 mL/min)

It's also important to note that the Perioperative Pain and Addiction Interdisciplinary Network published a clinical practice advisory for the perioperative management of buprenorphine in August 2019, but this does not directly apply to Lyrica management 1. However, the general principle of continuing perioperative medications when possible is supported by the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement 1.

In terms of specific management strategies, the following may be considered:

• Continuing Lyrica perioperatively without interruption for patients already on the medication
• Initiating Lyrica preoperatively for opioid-tolerant patients or those with neuropathic pain
• Using gabapentin as a temporary substitute if oral administration is not possible postoperatively
• Monitoring for side effects and adjusting the dose as needed in patients with renal impairment.

From the FDA Drug Label

Pregabalin is eliminated from the systemic circulation primarily by renal excretion as unchanged drug with a mean elimination half-life of 6.3 hours in subjects with normal renal function.

The management of Lyrica (pregabalin) perioperatively is not directly addressed in the provided drug label. Key considerations for perioperative management may include:

• Renal function: Pregabalin clearance is nearly proportional to creatinine clearance (CLcr), and dosage reduction may be necessary in patients with renal dysfunction.
• Elimination half-life: Pregabalin has a mean elimination half-life of 6.3 hours in subjects with normal renal function. However, without explicit guidance from the drug label, no conclusion can be drawn regarding the specific management of Lyrica perioperatively 2.

From the Research

Perioperative Management of Lyrica

There are no research papers to assist in answering this question as the provided studies do not mention Lyrica (pregabalin) in the context of perioperative management. However, one study 3 discusses the efficacy and safety of perioperative pregabalin for post-operative pain.

Alternative Antiepileptic Drugs

Other studies compare the efficacy of levetiracetam and phenytoin in preventing post-traumatic seizures:

• A systematic review found no significant difference in the incidence of late post-traumatic seizures between levetiracetam and phenytoin 4.
• A meta-analysis revealed no change in the rate of early post-traumatic seizures with levetiracetam compared to phenytoin 5.
• The concurrent use of phenytoin and levetiracetam for seizure prophylaxis in ICU patients has been analyzed, but the efficacy of this combination is still not fully clear 6.

Refractory Status Epilepticus

In the acute management of refractory status epilepticus in patients with brain tumors, a combination of phenytoin, levetiracetam, and pregabalin has been used with some success:

• A retrospective chart review found that cessation of status epilepticus was seen in 70% of patients after administration of phenytoin, levetiracetam, and pregabalin 7.

Some key points to consider:

• The use of levetiracetam and phenytoin in preventing post-traumatic seizures has been studied, but the results are inconclusive.
• Pregabalin has been used in the management of post-operative pain and refractory status epilepticus, but its use in the perioperative management of Lyrica is not well-studied.
• The combination of phenytoin, levetiracetam, and pregabalin may be effective in managing refractory status epilepticus in patients with brain tumors.