What is a suitable tapering protocol for a patient with Attention Deficit Hyperactivity Disorder (ADHD) who has been taking dextroamphetamine (Dex) for 3 years, and has used pregabalin on and off for 3 weeks with low doses of 150mg, then high doses of 600-1200mg in the third week, to minimize withdrawal symptoms and maintain functionality for an upcoming exam in 3 days?

Pregabalin Tapering Protocol for Short-Term Use with Upcoming Exam

For this patient with only 3 weeks of pregabalin use (not chronic use), taper over 3-5 days by reducing 25-33% daily, which is sufficient to prevent withdrawal while maintaining cognitive function for the exam. 1

Critical Context for This Case

This situation differs fundamentally from chronic benzodiazepine or long-term pregabalin use discussed in most guidelines. Your patient used pregabalin intermittently for only 3 weeks—this is not chronic dependence requiring months-long tapers. The FDA label specifies tapering "over a minimum of 1 week" when discontinuing pregabalin, but this is a conservative recommendation primarily for chronic therapeutic use 1.

Recommended Rapid Taper Protocol

Day 1-2: 450 mg/day (divided into 150 mg three times daily)

• This represents a 25-33% reduction from the high-dose range 1
• Maintains some GABAergic activity to prevent acute withdrawal 2

Day 3-4: 300 mg/day (divided into 100 mg three times daily)

• Another 33% reduction from current dose 1
• Still within therapeutic range for anxiety effects 2

Day 5: 150 mg/day (50 mg three times daily)

• Final step before discontinuation 1

Day 6: Discontinue completely

• Short exposure period (3 weeks) significantly reduces physiological dependence risk 3, 2

Rationale for Rapid Taper in This Case

Short duration of use: Withdrawal severity correlates with duration of exposure. Three weeks is insufficient to establish the degree of dependence requiring extended tapers 3, 2. Studies show withdrawal symptoms after pregabalin discontinuation are "mild" following short-term use and resolve within days 2.

Exam timing: A 5-day taper allows 2 days before the exam for stabilization. Pregabalin has a 6.3-hour half-life, meaning it clears rapidly—by exam day, the patient will be essentially drug-free with minimal residual sedation 2.

Functional preservation: The patient reports pregabalin enhances focus (atypical response), but this likely represents euphoric/stimulant-like effects at high doses rather than true cognitive enhancement 4. Continuing pregabalin through the exam risks dose escalation, cognitive impairment from high doses, and establishes a pattern of using pregabalin as a "study drug" 4.

Managing the Dexamphetamine Component

Continue dexamphetamine at current stable dose throughout the taper. 5, 6

• The patient has been successfully maintained on dexamphetamine for 3 years—this is the appropriate ADHD treatment 5, 6
• Do not adjust dexamphetamine dosing during pregabalin taper 5
• Dexamphetamine provides legitimate cognitive enhancement for ADHD and will support exam performance 5, 6

The patient's perception that pregabalin "increases focusing effects" likely reflects either anxiolytic effects reducing performance anxiety, or euphoric/stimulant-like effects from high-dose misuse 4. True ADHD treatment comes from the dexamphetamine 6.

Monitoring During Taper

Daily check-ins (phone or in-person) during the 5-day taper: 3

• Assess for withdrawal symptoms: anxiety, insomnia, headache, nausea, sweating 3, 2
• Monitor for seizures (rare but possible with abrupt cessation from very high doses) 3
• Evaluate mood and cognitive function 3

Expected withdrawal symptoms are mild: dizziness, anxiety, insomnia, headache 2. These typically peak 24-48 hours after dose reduction and resolve within days with short-term use 2.

Adjunctive Symptomatic Management

For anxiety during taper: Consider short-term use of hydroxyzine 25-50 mg as needed (non-addictive anxiolytic) 7

For insomnia: Trazodone 25-50 mg at bedtime if needed (avoid establishing another dependency) 7

Avoid: Adding benzodiazepines, which would substitute one dependency for another 7

Critical Safety Considerations

Seizure risk: While pregabalin withdrawal can cause seizures, this risk is primarily with abrupt cessation from chronic high-dose use 3. Your patient's 3-week exposure significantly reduces this risk, but the 5-day taper provides additional safety margin 3, 2.

Rebound anxiety: May occur but should be manageable with continued dexamphetamine and short-term anxiolytic support 2

Study performance: The patient will likely perform better on the exam without pregabalin. High-dose pregabalin (600-1200 mg) causes cognitive impairment, not enhancement 4. The dexamphetamine provides appropriate ADHD treatment 6.

Post-Exam Plan

After the exam, address the underlying issue: Why did the patient escalate to 600-1200 mg/day? 4

• This dosing pattern (low doses initially, then dramatic escalation) suggests emerging misuse 4
• Patients who use pregabalin above recommended dosages often have co-occurring substance use issues 4
• Consider referral to addiction medicine if pattern continues 3

Optimize ADHD treatment: Ensure dexamphetamine dosing is adequate so the patient doesn't seek cognitive enhancement from other substances 6

Common Pitfall to Avoid

Do not treat this as chronic benzodiazepine dependence requiring months-long taper. 7 The extensive benzodiazepine tapering guidelines in the evidence (10% monthly reductions, 6-12 month tapers) apply to patients with years of daily use 7. Your patient used pregabalin intermittently for 3 weeks—applying chronic dependence protocols would be inappropriate and unnecessarily prolonged 2.

The FDA label's "minimum of 1 week" taper recommendation is conservative and designed for all patients; clinical judgment allows for faster tapers in short-term use cases 1. The 5-day protocol balances safety with the practical need for the patient to be clear-headed for the exam.