Tapering Pregabalin 50mg (150mg/day total) in an Elderly Female
For this elderly female taking pregabalin 150mg/day (50mg AM, 100mg bedtime), taper gradually over a minimum of 4 weeks by reducing the dose by approximately 25% weekly, extending to 6-8 weeks if withdrawal symptoms emerge. 1, 2
Recommended Tapering Schedule
Week 1: Reduce to 125mg/day total
Week 2: Reduce to 100mg/day total
- Morning: 25mg (reduce by 25mg)
- Bedtime: 75mg (unchanged) 1
Week 3: Reduce to 50mg/day total
- Morning: 25mg (unchanged)
- Bedtime: 25mg (reduce by 50mg) 1
Week 4: Discontinue completely
Critical Considerations for Elderly Patients
Elderly patients require slower tapering than younger adults due to increased vulnerability to withdrawal symptoms, falls, confusion, and sedation. 3, 1 The FDA mandates tapering over a minimum of 1 week, but this is insufficient for elderly patients who should extend the taper to 4-8 weeks. 2
If withdrawal symptoms occur at any step, extend each reduction phase to 2 weeks instead of 1 week before proceeding to the next dose reduction. 1 This patient is at higher risk given her bedtime-weighted dosing pattern (100mg at night), which may have been addressing sleep or evening pain.
Monitoring During Taper
Watch closely for these withdrawal symptoms:
- Psychiatric symptoms: Insomnia, anxiety, agitation (most common) 4, 5
- Vegetative symptoms: Headache, nausea, sweating 1, 4
- Neurologic symptoms: Dizziness, tremor, confusion 1, 5
- Return of original pain for which pregabalin was prescribed 1
Withdrawal symptoms can emerge even after gradual tapers and may appear 1-10 days after dose reduction, typically resolving within 1 week if the taper is slowed. 4, 6
Special Precautions for This Patient
Assess renal function before initiating taper. Pregabalin is 95% renally excreted unchanged, and elderly patients often have age-related decline in renal function masked by normal serum creatinine due to reduced muscle mass. 3, 7, 8 Calculate creatinine clearance using Cockcroft-Gault equation; if CrCl <60 mL/min, this patient may have been inadvertently overdosed and withdrawal risk increases. 3
The bedtime-weighted dosing (100mg at night vs 50mg morning) suggests this patient may experience rebound insomnia or evening pain during taper. Consider maintaining the bedtime dose longer and reducing the morning dose first, as outlined in the schedule above. 1
Critical Pitfalls to Avoid
Do not use a one-week taper in elderly patients despite FDA labeling allowing this. Research demonstrates that even gradual tapers over 1 week can produce severe withdrawal symptoms in geriatric patients, including debilitating mental status changes and somatic complaints. 6
Do not assume short-term use prevents withdrawal. Pregabalin withdrawal can occur after as little as 2 months of regular use at therapeutic doses. 5
If severe withdrawal symptoms develop, immediately reinstate the previous dose. Symptoms typically resolve within 1-2 days of pregabalin reintroduction, then attempt a slower taper. 6
Monitor for falls risk throughout the taper period, as elderly patients are particularly vulnerable to dizziness, confusion, and balance disturbances during dose changes. 9, 3