What is a suitable pregabalin (lyrica) tapering schedule for an adult patient with normal renal function, currently taking 200 mg once daily, to gradually decrease to 0 mg?

Pregabalin Tapering Schedule from 200 mg Daily to Discontinuation

For a patient on pregabalin 200 mg once daily with normal renal function, taper by reducing the dose by 25-50 mg every 1-2 weeks, extending the taper over a minimum of 6-8 weeks to avoid withdrawal symptoms, with slower reductions (10-25 mg decrements) as you approach the final 50-100 mg. 1, 2

Recommended Tapering Protocol

Weeks 1-2: Reduce to 150 mg daily

• Decrease from 200 mg to 150 mg once daily 1
• Monitor for withdrawal symptoms including anxiety, insomnia, nausea, pain, or sweating 3

Weeks 3-4: Reduce to 100 mg daily

• Decrease from 150 mg to 100 mg once daily 1
• This represents a 50 mg reduction, which is well-tolerated at higher dose ranges 2

Weeks 5-6: Reduce to 75 mg daily

• Decrease from 100 mg to 75 mg once daily 1
• Begin slower taper increments as you approach lower doses 2

Weeks 7-8: Reduce to 50 mg daily

• Decrease from 75 mg to 50 mg once daily 1
• Smaller decrements (25 mg) are recommended in the lower dose range 2

Weeks 9-10: Reduce to 25 mg daily

• Decrease from 50 mg to 25 mg once daily 2
• The final 50-100 mg requires the slowest taper to minimize withdrawal 2

Weeks 11-12: Discontinue

• Decrease from 25 mg to 0 mg 2
• Consider extending this final step to 2-3 weeks if withdrawal symptoms emerge 2

Critical Considerations for Safe Tapering

Withdrawal Symptom Monitoring

• Pregabalin should not be discontinued abruptly, as this can precipitate withdrawal symptoms 1, 3
• Common withdrawal symptoms include anxiety, insomnia, nausea, pain, sweating, and in severe cases, seizures 3
• If significant withdrawal symptoms occur at any step, hold at the current dose for an additional 1-2 weeks before proceeding 2

Alternative Slower Taper for High-Risk Patients

• Patients with prolonged use (>6 months), higher doses, or history of substance use disorders may require a more gradual taper extending 3-6 months 2
• For these patients, reduce by 25 mg every 2-4 weeks, and when reaching 100 mg, switch to 10-20 mg decrements every 2-4 weeks 2
• The case report of severe gabapentinoid dependence required 18 months with 5 mg decrements in the final phase, though this represents an extreme scenario 2

Hyperbolic vs. Linear Tapering

• While linear tapering (equal dose reductions) is most commonly recommended in guidelines, hyperbolic tapering (reducing by a constant percentage rather than absolute amount) may better prevent withdrawal symptoms 4
• The schedule above uses a modified approach with larger absolute reductions at higher doses and smaller reductions at lower doses, approximating a hyperbolic curve 2, 4

Common Pitfalls to Avoid

Do Not Taper Too Rapidly

• The minimum taper duration should be 1 week, but 6-8 weeks or longer is strongly preferred for a 200 mg daily dose 1, 2
• Rapid tapers significantly increase the risk of withdrawal symptoms and treatment failure 2, 3

Do Not Use Fixed Percentage Reductions Throughout

• Reducing by 25% of the current dose at each step results in progressively smaller absolute reductions, which may be too slow at higher doses but appropriate at lower doses 5, 2
• The recommended approach uses larger absolute reductions (50 mg) at higher doses and smaller reductions (25 mg or less) at lower doses 2

Do Not Ignore Withdrawal Symptoms

• If withdrawal symptoms emerge, pause the taper and maintain the current dose for 1-2 additional weeks before attempting further reduction 2
• In cases of severe withdrawal, consider increasing back to the previous dose and implementing a slower taper schedule 2

Practical Dosing Challenges

• Pregabalin is available in 25 mg, 50 mg, 75 mg, 100 mg, 150 mg, 200 mg, 225 mg, and 300 mg capsules, allowing for the recommended taper increments 1
• For doses not available as single capsules (such as 125 mg), use combination dosing (e.g., 100 mg + 25 mg) 4

Special Population Considerations

Elderly Patients

• Consider extending the taper duration by 50-100% (12-16 weeks minimum) due to increased vulnerability to withdrawal symptoms and adverse effects 1
• Monitor more closely for dizziness, confusion, and fall risk during the taper 1

Patients with Renal Impairment

• Although this patient has normal renal function, any decline in renal function during the taper would require dose adjustment, as pregabalin is eliminated unchanged by the kidneys 1, 6

Concurrent CNS Depressants

• Patients taking opioids, benzodiazepines, or other CNS depressants require closer monitoring during pregabalin taper due to increased risk of withdrawal symptoms and potential for synergistic sedative effects 1