Initial Dose of Lyrica (Pregabalin) for Anxiety
Pregabalin is not FDA-approved for anxiety disorders, and the provided evidence does not contain FDA-approved dosing for this indication. However, based on research evidence in generalized anxiety disorder, the typical starting dose is 150 mg/day divided into two or three doses, with potential titration to 300-600 mg/day based on response and tolerability 1, 2.
Dosing Strategy
Starting Dose
- Begin with 150 mg/day divided into 2-3 doses (e.g., 75 mg twice daily or 50 mg three times daily) 1, 2
- Alternative low-dose initiation: Some clinicians recommend starting at 25-50 mg at bedtime to minimize side effects, particularly somnolence and dizziness, then uptitrating weekly 3
Titration Schedule
- Increase to 300 mg/day within one week if the initial dose is tolerated and additional efficacy is needed 4
- Further increases by 150 mg/day every 3-7 days as tolerated, up to a maximum of 600 mg/day 4
- The 600 mg/day dose can be administered as 200 mg three times daily or 300 mg twice daily 4
Optimal Therapeutic Dose
- Most patients respond to 300-600 mg/day in clinical trials for generalized anxiety disorder 1, 2
- Doses above 300 mg/day are not consistently more effective but are associated with greater adverse effects 4
- Anxiolytic effects may be apparent within one week of treatment initiation 1
Critical Considerations
Renal Impairment
- Mandatory dose reduction for eGFR <30 mL/min, as pregabalin is excreted largely unchanged by the kidneys 4, 5
- Reduce doses proportionally based on creatinine clearance 4
Tolerability Management
- Most common adverse effects are dizziness (23-49%) and somnolence (14-50%), which are dose-dependent 1, 6, 2
- Tolerance to these effects typically develops within a few weeks 1
- Slower titration is warranted in frail elderly or those with renal impairment 4
Treatment Duration
- Allow 4 weeks for an adequate therapeutic trial before determining efficacy 4
- Pregabalin should be discontinued gradually to minimize withdrawal symptoms 3
Drug Interactions
- Pregabalin has no significant drug-drug interactions due to lack of protein binding and negligible hepatic metabolism 5, 3
- May worsen sedation when combined with CNS depressants 3
Important Caveats
Monitor for emergence or worsening of depression and suicidal thoughts or behavior in all patients treated with pregabalin 3. Weight gain and peripheral edema are dose-related side effects that should be monitored 3, 6.