Does Lyrica Help with Pain?
Yes, Lyrica (pregabalin) is effective for specific types of neuropathic pain, including postherpetic neuralgia, painful diabetic neuropathy, fibromyalgia, and spinal cord injury-related neuropathic pain, but it does NOT work for all pain conditions.
FDA-Approved Indications
Pregabalin is FDA-approved for the following pain conditions 1:
- Neuropathic pain associated with diabetic peripheral neuropathy
- Postherpetic neuralgia (pain following shingles)
- Fibromyalgia
- Neuropathic pain associated with spinal cord injury
Efficacy by Condition
Postherpetic Neuralgia (Strongest Evidence)
- At 300 mg daily: 50% of patients achieve at least 30% pain reduction versus 25% with placebo (NNTB 3.9), and 32% achieve at least 50% pain reduction versus 13% with placebo (NNTB 5.3) 2
- At 600 mg daily: 62% achieve at least 30% pain reduction versus 24% with placebo (NNTB 2.7), and 41% achieve at least 50% pain reduction versus 15% with placebo (NNTB 3.9) 2
- This represents the best response among all neuropathic pain conditions 3
Painful Diabetic Neuropathy
- At 300 mg daily: 47% achieve at least 30% pain reduction versus 42% with placebo (NNTB 22), and 31% achieve at least 50% pain reduction versus 24% with placebo 2
- At 600 mg daily: 63% achieve at least 30% pain reduction versus 52% with placebo (NNTB 9.6), and 41% achieve at least 50% pain reduction versus 28% with placebo (NNTB 7.8) 2
- The CDC guidelines confirm pregabalin is associated with small improvements in diabetic neuropathy and is FDA-approved for this indication 3
Fibromyalgia
- Pregabalin produces small to moderate improvements in pain, function, and quality of life at doses of 300-600 mg daily 3
- The NNTB is higher (around 11) compared to other neuropathic conditions, meaning fewer patients achieve substantial benefit 4
- FDA-approved and recommended by the CDC for fibromyalgia treatment 3
Spinal Cord Injury-Related Neuropathic Pain
- At doses of 150-600 mg daily, pregabalin statistically significantly improved pain scores and increased the proportion of patients with at least 30% and 50% pain reduction 1
- Some patients experienced pain decrease as early as week 1 that persisted throughout 12-16 week studies 1
Central Neuropathic Pain
- At 600 mg daily: 44% achieve at least 30% pain reduction versus 28% with placebo (NNTB 5.9), and 26% achieve at least 50% pain reduction versus 15% with placebo (NNTB 9.8) 2
Conditions Where Pregabalin Does NOT Work
HIV-Associated Neuropathy (Critical Caveat)
- Two large randomized controlled trials showed pregabalin was NO better than placebo for HIV-associated distal sensory polyneuropathy 3
- One trial with 302 patients and another with 377 patients were both terminated early for futility 3
- Moderate-quality evidence demonstrates no efficacy in HIV neuropathy 2
Acute Postoperative Pain
- There is no clear evidence of beneficial effects in established acute postoperative pain 4
- No evidence supports pregabalin use in acute pain scenarios 4
Chronic Low Back Pain
- The CDC guidelines recommend NSAIDs or duloxetine for chronic low back pain, not pregabalin 3
Dosing Strategy
Starting and Titration
- Start with 50 mg three times daily or 75 mg twice daily 5
- Increase to 300 mg/day after 3-7 days if tolerated 5
- If pain relief is insufficient, increase by 150 mg/day every 3-7 days up to maximum 600 mg/day 5
- For diabetic peripheral neuropathy and postherpetic neuralgia, the effective dose range is 150-600 mg/day in divided doses 5
Time to Effect
- Some patients experience pain decrease as early as week 1 1
- Full assessment of efficacy requires 4 weeks of treatment 5
Special Populations
- Elderly patients or those with renal impairment: Use lower starting doses and slower titration 5
- Patients on hemodialysis: Dose adjustments required due to renal elimination 6
Adverse Effects Profile
Common Side Effects (Dose-Dependent)
At 300 mg daily 2:
- Somnolence: 11-16% versus 3-5.5% with placebo
- Dizziness: 13-29% versus 3.8-8.1% with placebo
At 600 mg daily 2:
- Somnolence: 15-25% versus 4.5-5.8% with placebo
- Dizziness: 22-35% versus 4.4-8.8% with placebo
Discontinuation Rates
- 18-28% of patients discontinue due to adverse events at 600 mg daily 3
- Serious adverse events occur at similar rates to placebo (approximately 3%) 2
Serious Warnings
The FDA requires warnings for 1:
- Serious, life-threatening allergic reactions (angioedema)
- Suicidal thoughts or actions (like other antiepileptic drugs)
- Serious breathing problems when combined with opioids or in patients with existing respiratory issues
- Swelling of hands, legs, and feet (particularly concerning in patients with heart failure)
- Dizziness and sleepiness affecting ability to drive or operate machinery
Drug Interactions
Increased Risk of Adverse Effects
- ACE inhibitors: Higher chance of swelling and hives 1
- Thiazolidinediones (rosiglitazone, pioglitazone): Increased weight gain and peripheral edema 1
- Opioids, benzodiazepines, or sedatives: Significantly increased risk of dizziness, sleepiness, and serious breathing problems 1
Clinical Decision Algorithm
Use pregabalin when:
- Patient has postherpetic neuralgia, painful diabetic neuropathy, fibromyalgia, or spinal cord injury-related neuropathic pain 1
- Patient does NOT have HIV-associated neuropathy 3
- Patient is not seeking treatment for acute pain or chronic low back pain 3, 4
- Patient does not have contraindications (severe respiratory disease, history of angioedema) 1
Expect best results in:
Expect modest results in:
Do NOT use in:
Realistic Expectations
- A minority of patients will have substantial benefit (≥50% pain reduction) 4, 2
- More will have moderate benefit (30-49% pain reduction) 4, 2
- Many will have no benefit or will discontinue due to adverse events 4, 2
- Higher doses (600 mg daily) generally produce better pain relief but with increased side effects 2