A patient with lumbar spondylosis‑related radiculopathy who feels better on pregabalin and baclofen – what is the appropriate next step in management?

Continue Current Therapy and Optimize Dosing

Since the patient is responding well to pregabalin and baclofen for lumbar spondylosis-related radiculopathy, continue both medications while optimizing pregabalin to therapeutic dosing (150-300 mg twice daily) and plan to taper baclofen after 1-2 weeks, as muscle relaxants have no evidence for efficacy beyond this timeframe. 1

Immediate Management Steps

Optimize Pregabalin Dosing

• Ensure pregabalin is at therapeutic dose of 150-300 mg twice daily (not just 75 mg twice daily), as this targets the neuropathic component of radiculopathy effectively 2
• Pregabalin shows superior short-term pain reduction compared to gabapentin in lumbar radiculopathy (mean difference of -0.31 on pain scales at 6 weeks or less), though long-term outcomes are equivalent 3
• Monitor for sedation, dizziness, and peripheral edema during dose escalation 1

Address the Baclofen Component

• Baclofen (or any muscle relaxant) must be discontinued after 1-2 weeks maximum, as all trials of skeletal muscle relaxants were ≤2 weeks duration with no evidence supporting efficacy beyond this timeframe 1
• Begin tapering baclofen now if the patient has been on it for more than 1-2 weeks 1
• The patient's improvement may be primarily from pregabalin rather than baclofen, as muscle relaxants show inconsistent evidence for radiculopathy 1

Add First-Line NSAID Therapy

Initiate or Continue NSAID

• Start naproxen 500 mg twice daily or celecoxib 100-200 mg daily to target the inflammatory component of radicular pain, as NSAIDs are recommended first-line therapy by the American College of Physicians with moderate short-term efficacy 4, 2
• Use the lowest effective dose for the shortest necessary period, monitoring cardiovascular and gastrointestinal risk factors 1
• Selective COX-2 inhibitors like celecoxib have fewer gastrointestinal side effects than traditional NSAIDs 1

Reassessment Timeline

4-Week Follow-Up

• Evaluate pain control on optimized pregabalin (150-300 mg twice daily) plus NSAID after baclofen taper 1
• If pain remains uncontrolled despite therapeutic pregabalin dosing, add nortriptyline 10-25 mg nightly (preferred over amitriptyline in elderly due to fewer anticholinergic effects) or duloxetine 30-60 mg daily 1
• The combination of nortriptyline and gabapentinoids has shown superiority over either medication alone in neuropathic pain 1

6-8 Week Follow-Up

• If insufficient response to optimized medications within 4-6 weeks, refer to pain management or spine specialist for consideration of epidural steroid injections or surgical evaluation 1
• Note that lumbosacral radiculopathy appears relatively refractory to standard neuropathic pain medications compared to other neuropathic conditions 1

Critical Pitfalls to Avoid

• Do NOT continue baclofen beyond 1-2 weeks – no evidence supports chronic use, and it increases fall risk through sedation 1
• Do NOT use systemic corticosteroids – they are ineffective compared to placebo for radiculopathy according to the American College of Physicians 1, 4
• Do NOT use benzodiazepines – they are ineffective for radiculopathy based on low-quality evidence 1, 4
• Do NOT underdose pregabalin – doses below 150 mg twice daily provide minimal analgesic effect for radiculopathy 1

Alternative Considerations

• If pregabalin causes intolerable sedation (44% dropout rate in one Asian study), consider switching to gabapentin 1200-3600 mg/day in divided doses, though pregabalin shows better short-term pain reduction 3, 5
• Duloxetine 30-60 mg daily is an alternative if depression coexists, with moderate evidence for small improvements in pain intensity (0.60-0.79 points on 0-10 scale) and function 1