What is the appropriate pregabalin dose to augment sertraline 100 mg daily in a 69‑year‑old woman with generalized anxiety disorder?

Pregabalin Dosing for GAD Augmentation in a 69-Year-Old Woman

I cannot recommend pregabalin augmentation of sertraline for generalized anxiety disorder, as the available evidence addresses pregabalin for neuropathic pain management (not GAD) and alcohol dependence maintenance (not GAD). The provided guidelines are from neuropathic pain treatment protocols and do not apply to anxiety disorders 1.

Critical Evidence Gap

The evidence provided consists primarily of:

• Neuropathic pain dosing guidelines from Mayo Clinic Proceedings (2010), which recommend pregabalin starting at 50 mg three times daily or 75 mg twice daily, titrating to 300 mg/day after 3-7 days, with a maximum of 600 mg/day 1.
• Alcohol dependence studies from BMJ (2020), which show pregabalin had low-quality evidence with only 31 participants studied 1.

However, the research studies on pregabalin for GAD suggest:

• Effective doses range from 150-600 mg/day for GAD, with peak efficacy around 450 mg/day for overall anxiety symptoms 2.
• Psychic anxiety symptoms peak at approximately 400 mg/day, while somatic symptoms may benefit from doses up to 600 mg/day 2.
• Rapid onset of action occurs within the first week, faster than SSRIs like sertraline 3, 4.

Geriatric Considerations for This 69-Year-Old Patient

Lower starting doses and slower titration are essential in geriatric patients due to increased risk of dizziness, sedation, and mental clouding 1.

• Starting dose should be 25-50 mg/day (lower than standard adult dosing) 1.
• Dose escalation should be incremental with intervals long enough to monitor for adverse effects, particularly somnolence, dizziness, and cognitive impairment 1, 5.
• Renal function must be assessed, as pregabalin requires dose reduction in renal insufficiency, which is more common in older adults 1.

Common Pitfalls

• Avoid standard adult starting doses (150 mg/day) in this 69-year-old patient, as tolerability issues are significantly more problematic in older adults 1.
• Monitor for falls risk, as dizziness and sedation are the most common adverse effects (reported in 28% of patients) 3, 5.
• Assess for drug interactions, though pregabalin has few significant interactions 1.