Pregabalin Taper Plan for Intractable Nausea and Vomiting
Immediate Discontinuation Strategy
For a patient experiencing intractable nausea and vomiting on pregabalin 75 mg, discontinue the medication with a gradual taper over a minimum of 1 week, as abrupt discontinuation can cause withdrawal symptoms including nausea, headache, anxiety, and diarrhea. 1
Recommended Taper Schedule
Taper pregabalin 75 mg over 7-14 days using the following schedule:
- Days 1-3: Reduce to 50 mg daily 1
- Days 4-6: Reduce to 25 mg daily 1
- Days 7-10: Reduce to 25 mg every other day 1
- Day 11+: Discontinue completely 1
The FDA label explicitly states that pregabalin should be tapered gradually over a minimum of 1 week rather than discontinued abruptly to minimize withdrawal symptoms 1. However, given the severity of intractable nausea and vomiting, a slightly longer taper of 10-14 days may be warranted based on evidence from similar medications 2, 3.
Managing Nausea During the Taper
Initiate aggressive antiemetic therapy immediately while tapering pregabalin:
First-Line Antiemetic Treatment
- Start with a dopamine receptor antagonist: Metoclopramide 10 mg PO three times daily before meals, or prochlorperazine 10 mg PO every 6 hours, or haloperidol 0.5-1 mg PO every 6-8 hours 4, 5
- Administer around-the-clock rather than as-needed for the first week of taper 5
Second-Line Addition if Nausea Persists
- Add a 5-HT3 receptor antagonist: Ondansetron 8 mg PO twice daily or granisetron 1 mg PO twice daily 4, 6, 5
- Use sublingual formulations if oral absorption is compromised by vomiting 6
Alternative Routes if Oral Intake Fails
- Consider rectal suppositories (prochlorperazine or promethazine) or intravenous administration if vomiting prevents oral medication absorption 6
- Ondansetron 0.15 mg/kg IV over 15 minutes (maximum 16 mg per dose) can be used for severe symptoms 6
Critical Monitoring During Taper
Monitor closely for withdrawal symptoms that may overlap with or worsen nausea:
- Withdrawal symptoms typically include insomnia, nausea, headache, anxiety, hyperhidrosis, and diarrhea 1
- These symptoms can emerge within 1-2 days of dose reduction and may persist for up to 1 week after complete discontinuation 7, 8
- If severe withdrawal symptoms develop, slow the taper rate further or temporarily increase the dose before resuming a slower taper 3
Important Clinical Pitfalls to Avoid
Do not abruptly discontinue pregabalin even in the setting of severe adverse effects, as this increases the risk of withdrawal symptoms that may compound the existing nausea 1. The case literature demonstrates that even gradual tapers over 1 week can produce withdrawal symptoms in some patients, particularly in older adults 7, 2.
Do not mistake withdrawal symptoms for worsening of the original condition. Pregabalin withdrawal can cause nausea itself, which may be difficult to distinguish from the medication-induced nausea 1, 7. If symptoms worsen during taper, consider temporarily holding at the current dose for 2-3 days before continuing the taper 3.
Ensure adequate hydration and correct electrolyte abnormalities that may result from persistent vomiting 6. Dehydration can worsen both nausea and potential withdrawal symptoms 4.
Special Considerations
For patients with renal impairment, pregabalin clearance is reduced, which may prolong withdrawal symptoms and necessitate an even slower taper 1.
If the patient has been on pregabalin for an extended period (months to years), consider extending the taper to 2-3 weeks, as longer duration of use is associated with more pronounced withdrawal symptoms 7, 2, 9.
Reassess after complete discontinuation: If nausea persists beyond 1 week after pregabalin discontinuation, investigate other potential causes including gastritis, gastroparesis, or other medication effects 4, 5.