What are the treatment options for a pregabalin (Lyrica) overdose exceeding 75mg?

Pregabalin Overdose Management

For a pregabalin overdose exceeding 75mg, provide supportive care as the primary treatment, including airway protection and monitoring of vital signs, as there is no specific antidote for pregabalin toxicity. 1

Immediate Assessment and Monitoring

• Observe the patient closely for neurological depression, which typically develops 2-4 hours post-ingestion, with peak toxicity occurring around 3 hours after overdose 2
• Monitor for the most common overdose symptoms: reduced consciousness, depression/anxiety, confusional state, agitation, and restlessness 1
• Watch for serious complications including seizures (occurring in approximately 2-5% of cases) and heart block, though these are uncommon 1, 3
• Coma (GCS <9) occurs in approximately 18% of pregabalin overdoses, but nearly all cases requiring intubation involve co-ingestion of sedating agents like opioids or benzodiazepines 3

Supportive Care Protocol

• Maintain airway patency - endotracheal intubation and mechanical ventilation may be required for patients with significant neurological depression or coma 2
• Monitor vital signs continuously, particularly for hypotension (occurs in 5% of cases, typically only with co-ingestants) 3
• Provide general supportive care including observation of clinical status until consciousness improves 1
• The median length of hospital stay for pregabalin overdose is approximately 16.5 hours (range 10-25 hours) 3

Decontamination Considerations

• If indicated and the patient presents early, elimination of unabsorbed drug may be attempted by emesis or gastric lavage, though this is rarely practical given the typical 3-hour delay to symptom onset 1, 2
• Observe usual precautions to maintain airway protection during any decontamination procedures 1

Enhanced Elimination Options

• Hemodialysis removes approximately 50% of pregabalin in 4 hours and should be considered in severe cases with extremely high serum concentrations (>60-66 mg/L) 1, 2
• However, supportive care alone is often sufficient even in cases with serum pregabalin concentrations as high as 66.5 mg/L, as demonstrated in published case reports 2
• The decision to use hemodialysis should be based on clinical severity rather than dose alone, as patients have recovered with supportive measures only even after ingesting 8.4 grams 2

Critical Assessment for Co-Ingestions

• Co-ingestions occur in 88% of pregabalin overdose presentations, with sedating agents present in 79% of cases 3
• The most common co-ingestants are opioids (41% of cases) and benzodiazepines (36% of cases), which significantly increase the risk of respiratory depression and coma 3
• Severe toxicity (coma requiring intubation) is almost exclusively seen with co-ingestion of sedating agents - only 0.2% of intubated patients had pregabalin-only overdose 3
• Screen for concurrent CNS depressants, as deaths have been reported with combined pregabalin and other CNS depressant overdoses 1

Poison Control Consultation

• Contact a Certified Poison Control Center for up-to-date management guidance specific to the clinical scenario 1

Expected Clinical Course

• Pregabalin-only overdose typically causes mild sedation and uncommonly seizures, with severe toxicity being rare in the absence of co-ingestants 3
• Recreational pregabalin use is increasing, with doses often well above recommended levels (median overdose dose 1200 mg, range 75-16,800 mg) 3, 4
• Most patients recover fully with supportive care alone within 24 hours 2, 3