Lyrica. What diseases does it treat?

Use pregabalin (Lyrica) for neuropathic pain–including diabetic peripheral neuropathy and postherpetic neuralgia–fibromyalgia, neuropathic pain after spinal cord injury, and as adjunctive therapy for partial-onset seizures. Start at 150 mg/day (75 mg twice daily or 50 mg three times daily); increase to 300 mg/day within one week if tolerated, and consider titration up to 300–600 mg/day for neuropathic pain or seizure adjunct therapy based on clinical response and tolerability.

For fibromyalgia aim for doses between 150 and 450 mg/day; many patients report symptom relief at 300–450 mg/day. For adjunctive seizure control follow the same 150–600 mg/day range used in outpatient practice, split into two or three daily doses. Adjust dosing pace to patient tolerance: increase slowly when dizziness or somnolence occur.

Reduce doses in renal impairment according to creatinine clearance; pregabalin is primarily renally excreted. Patients on hemodialysis require a supplemental post-dialysis dose–refer to the manufacturer’s dosing table for exact amounts. Check renal function at baseline and periodically while on therapy.

Expect common adverse effects such as dizziness, somnolence, peripheral edema, weight gain, blurred vision and dry mouth. Counsel patients to avoid driving or heavy machinery until they know how pregabalin affects them. Combine with opioids, benzodiazepines or alcohol only with caution because of additive central nervous system depression and possible respiratory compromise.

Monitor mood and behavior for new or worsening depression or suicidal ideation; report any abrupt increases in seizure frequency. Do not stop pregabalin abruptly–taper over at least one week to reduce risk of withdrawal symptoms and seizure recurrence. Pregabalin has minimal hepatic metabolism and few pharmacokinetic drug interactions, but treat it as a Schedule V controlled substance where applicable and review pregnancy data with patients of childbearing potential.

Practical checklist: start 150 mg/day, target 300–600 mg/day by tolerability and indication, adjust for renal function and dialysis, warn about sedation and driving, counsel on mood changes, and taper when discontinuing; document baseline weight, renal function and mood before long-term therapy.

Dose initiation and titration for neuropathic pain in diabetic patients

Initiate pregabalin at 50 mg three times daily (150 mg/day) or 75 mg twice daily; increase to 100 mg three times daily (300 mg/day) within 3–7 days if tolerated and pain relief is insufficient.

Titrate stepwise: maintain the initial dose for 3–7 days, then increase to 100 mg TID (300 mg/day). If partial response after 1–2 weeks at 300 mg/day and tolerability allows, consider upward titration to 150 mg TID (450 mg/day). Maximum total daily dose for neuropathic pain may reach 600 mg/day in divided doses for selected patients, but most benefit for diabetic peripheral neuropathy is observed at 300 mg/day; reassess at each step for adverse effects and analgesic benefit.

Adjust dosing for renal impairment using creatinine clearance (CrCl, Cockcroft–Gault). General guidance: CrCl ≥60 mL/min – standard dosing per above; CrCl 30–59 mL/min – start ~75 mg/day and titrate toward 150–300 mg/day in divided doses; CrCl 15–29 mL/min – start ~25–75 mg/day in divided doses and titrate slowly; CrCl <15 mL/min or on hemodialysis – use substantially reduced doses and follow specific dialysis dosing recommendations from the product label. Calculate CrCl before initiation and document dose adjustments.

For older adults and patients with multiple CNS depressants, reduce the initial dose and slow titration. Example: consider starting at 25–50% of the usual initial dose and increase every 7–14 days while monitoring for dizziness, somnolence, and balance impairment. Review concurrent opioids, benzodiazepines, and alcohol; reduce combined sedative load where feasible to limit respiratory depression risk.

Manage adverse effects during titration by pausing escalation or reducing the current dose by approximately 50% if significant dizziness, somnolence, or gait disturbance appears. If mild side effects occur, extend each titration interval to 7–14 days. Monitor weight, peripheral edema, and mood changes; evaluate for new or worsening depressive symptoms or suicidal ideation per standard clinical practice.

Set measurable goals before titration: record baseline pain intensity and function, aim for ≥30% pain reduction or clear functional improvement. Assess response after 2–4 weeks at an optimized dose; if pain remains inadequate after 4–8 weeks at tolerable, near-maximal dose, switch or add alternative therapies. When stopping pregabalin, taper gradually over at least 1 week to reduce withdrawal symptoms and seizure risk.

Starting pregabalin for postherpetic neuralgia: timing, dosing, and response monitoring

Start pregabalin at 75 mg twice daily for most adults with postherpetic neuralgia (PHN); increase to 150 mg twice daily after 3–7 days if tolerated. Aim for a therapeutic dose of 300 mg/day (150 mg twice daily); escalate to 600 mg/day (300 mg twice daily) only when pain control remains inadequate and adverse effects are manageable.

• Titration example
  1. Day 1–3: 75 mg twice daily.
  2. Day 4–7: 150 mg twice daily (if tolerated).
  3. Week 2–4: assess response; if <30% pain reduction at 300 mg/day, consider increase to 300 mg twice daily with careful monitoring.
• When to start
  • Initiate when neuropathic features persist after the acute shingles phase and pain continues beyond the first few weeks (commonly treated once pain persists 4–12 weeks after rash), or earlier for severe neuropathic symptoms interfering with sleep or function.
• Renal dosing (examples; calculate creatinine clearance and adjust per product labeling)
  • CrCl ≥60 mL/min: standard dosing (75–300 mg twice daily as above).
  • CrCl 30–59 mL/min: reduce total daily dose by ~50% (example: 75 mg twice daily to 150 mg/day or 75 mg once daily to 150 mg/day depending on target).
  • CrCl 15–29 mL/min: further reduce (example: 50–75 mg once to twice daily or individualized lower totals).
  • CrCl <15 mL/min (not on dialysis) and end-stage renal disease: use small once-daily doses and follow specialist or product guidance.
  • Hemodialysis: administer a supplemental dose after each dialysis session per prescribing information (examples vary by baseline dose and dialysis schedule).

• Monitoring schedule and metrics
  • Baseline: record pain intensity (11-point numerical rating scale), sleep disturbance, mood, weight, and serum creatinine/CrCl.
  • Week 1–2: check adverse effects (dizziness, somnolence, peripheral edema), sedation, and early pain trend; adjust dose if intolerance emerges.
  • Week 4: formal efficacy assessment. Use ≥30% pain reduction or meaningful sleep/function improvement as success criteria; continue if met.
  • Month 2–3: reassess sustained benefit and adverse effects; if stable and beneficial, continue therapy and re-evaluate periodically every 3 months.
• Outcome actions
  • If ≥30% pain reduction at 4 weeks on 300 mg/day, maintain dose and monitor.
  • If <30% reduction at 4 weeks, consider increasing to 600 mg/day if tolerated, switching to another neuropathic agent, or combination therapy with nonoverlapping side-effect profiles.
  • If intolerable adverse effects occur, reduce dose or slow titration; consider alternative treatments.

• Safety and adverse-effect monitoring
  • Watch for dizziness, somnolence, balance disturbance–advise patients not to drive or operate heavy machinery until they know how the drug affects them.
  • Monitor weight and for peripheral edema; consider dose reduction if significant swelling or unexplained weight gain occurs.
  • Assess mood and suicidal ideation periodically; evaluate any new or worsening depression or behavioral changes.
  • Screen concomitant medications for CNS depressants (opioids, benzodiazepines, alcohol). Monitor for additive sedation and respiratory depression, particularly in older adults and patients with pulmonary disease.
  • Repeat renal function at least once within the first month and then according to clinical context; adjust dose when renal function changes.
• Tapering and discontinuation
  • Do not stop abruptly after weeks to months of therapy; reduce dose gradually over 1–2 weeks or longer for long-term users (example: decrease total daily dose by ~25% every 3–7 days until stopped).
  • If withdrawal-like symptoms (insomnia, nausea, headache, anxiety) appear, slow the taper further and reassess the need for ongoing treatment.
• Special populations
  • Elderly: start at lower dose (for example 25–75 mg twice daily or 75 mg once daily) and adjust according to tolerability and renal function.
  • Pregnancy and lactation: use only if benefits justify potential risks; discuss alternatives and document informed choices.

Pregabalin use in fibromyalgia: selection criteria and follow-up assessments

Offer pregabalin to patients with a confirmed fibromyalgia diagnosis and persistent moderate-to-severe widespread pain (NRS ≥4) or refractory sleep disturbance when nonpharmacologic measures and first-line pharmacotherapies have not produced acceptable symptom control.

Select patients based on: 2010/2016 ACR criteria or comparable clinical assessment; baseline pain intensity and functional impairment (document NRS, WPI and FIQR scores); absence of pregnancy or breastfeeding; renal function adequate for dosing or with a plan for adjustment; cautious approach for prior substance-use disorder or overlapping CNS depressant use. Defer initiation for acute unstable medical conditions or active decompensated heart failure until optimized.

Perform baseline assessments: serum creatinine/estimated CrCl or eGFR, weight, orthostatic vitals, visual symptoms, PHQ-9 for mood and suicidal ideation screening, medication reconciliation (opioids, benzodiazepines, gabapentinoids), and pregnancy test for women of childbearing potential. Record baseline validated outcomes: NRS, FIQR, PSQI and PGIC baseline rating.

Initiate dosing for fibromyalgia with low-step increases: typical regimens start at 75 mg twice daily (150 mg/day) and titrate over 1–2 weeks toward 300 mg/day; consider doses up to 450 mg/day for partial responders who tolerate therapy. Increase dose every 3–7 days as tolerated and reassess benefit. Adjust dose and/or frequency based on creatinine clearance using the product labeling; generally reduce total daily dose proportionally as CrCl declines and extend dosing interval for severe renal impairment or dialysis.

Schedule follow-up visits for safety and efficacy: early check at 1–2 weeks to review tolerability (dizziness, somnolence, peripheral edema, blurred vision, weight gain, cognitive slowing), formal efficacy assessment at 4 weeks, and comprehensive reassessment at 8–12 weeks. Use NRS and FIQR to quantify change; set a minimum clinical target of ≥30% reduction in pain or meaningful improvement in FIQR/PGIC by 8 weeks. If improvement is <30% and adverse effects limit dose escalation, discontinue or switch therapy.

Manage adverse effects proactively: reduce dose for pronounced dizziness or somnolence, advise against driving or operating machinery until individual response is known, monitor weight and signs of fluid retention, and investigate new visual disturbances. When co-prescribing opioids, benzodiazepines or alcohol, counsel on additive sedation and consider conservative pregabalin dosing with closer monitoring.

Taper gradually when stopping pregabalin to reduce withdrawal risk: reduce dose over 1–2 weeks for short-term treatment and consider a slower taper for long-term or high-dose therapy. For older adults, start at lower doses (for example, 25–50 mg/day or lower-step titration) and monitor for falls and cognitive effects.

Document treatment goals (pain reduction, sleep, function), track validated outcome scores at each visit, and revise the plan if objectives are unmet or adverse effects predominate. If sustained benefit is achieved, continue the lowest effective dose and reassess periodically (every 3–6 months) for ongoing efficacy and safety.

Adding pregabalin as adjunct therapy for focal (partial-onset) seizures in adults

Recommendation: For adults with focal (partial-onset) seizures refractory to one or two antiepileptic drugs, add pregabalin starting at 150 mg/day (75 mg twice daily) and increase to 300 mg/day after one week; consider a further increase to a maximum of 600 mg/day (divided) after a second week based on seizure control and tolerability.

Patient selection: Use adjunctive pregabalin when focal seizures persist despite optimized monotherapy or dual therapy and when the patient tolerates potential central nervous system effects. Avoid initiation in patients with a known hypersensitivity to pregabalin. Exercise extra caution in older adults, patients with respiratory compromise, unstable mood disorders, or significant renal impairment.

Dosing practicalities: Administer pregabalin in two divided doses (morning and evening); three-times-daily regimens are acceptable for individual tolerability. Adjust incremental increases only after assessing adverse effects during the preceding week. Limit the daily dose to 600 mg.

Renal dosing and dialysis: Modify dose according to creatinine clearance; reduce total daily dose and/or extend dosing interval with declining renal function. For patients receiving hemodialysis, give a supplemental dose after each dialysis session per product labeling.

Drug interactions and safety checks: Expect minimal pharmacokinetic interactions because pregabalin undergoes negligible hepatic metabolism. Screen for concurrent CNS depressants–benzodiazepines, opioids, sedating antiepileptics and alcohol–since additive sedation and respiratory depression can occur. Monitor for new or worsening dizziness, somnolence, ataxia and blurred vision within the first 2–4 weeks.

Monitoring schedule: Record baseline seizure frequency, weight and creatinine clearance. Reassess seizure counts and adverse effects at 1, 2 and 4 weeks after initiation and with each dose increase, then every 3 months once stable. Watch for peripheral edema, unexplained weight gain, cognitive slowing and mood changes; screen for suicidal ideation routinely.

Tapering and discontinuation: Reduce pregabalin gradually over at least one week when stopping to lower the risk of increased seizure frequency and withdrawal-related adverse effects. If seizures worsen during taper, restore the prior tolerated dose and reassess the regimen.

Communication note: Discuss expected onset of antiseizure benefit (often within 1–2 weeks of therapeutic dosing), potential side effects and renal-based dose adjustment at the first visit; document a follow-up plan that specifies when to escalate dose, when to stop for intolerance, and how seizure response will be measured.

Dose adjustments for renal impairment and elderly patients to reduce overdose risk

Adjust pregabalin dose according to measured creatinine clearance (use Cockcroft–Gault) and begin elderly patients at reduced doses with slower titration to avoid drug accumulation and excess sedation.

Practical dosing by renal function

Creatinine clearance (mL/min)	Recommended total daily dose (mg/day)	Typical dosing schedule	Notes
≥60	150–600	Divided BID or TID (e.g., 75 mg BID → up to 300 mg BID)	Usual adult range; titrate by indication and tolerability
30–59	75–300	Divided doses (e.g., 37.5–150 mg BID)	Reduce initial dose by ~50% versus normal renal function
15–29	25–150	Divided doses (e.g., 12.5–75 mg BID)	Use lower end of range for frail patients; extend dosing interval if needed
<15 (not dialysis)	25–75	Once daily or divided small doses	Start very low; titrate only with clear clinical benefit
Hemodialysis (4-hour sessions)	Supplemental dose after dialysis: 25–100	Give supplemental dose after each dialysis session	Pregabalin is dialyzable; baseline and post-dialysis dosing planning required

Practical elderly‑patient rules and monitoring

Begin elderly patients (especially ≥75 years or frail) at 25–75 mg/day in divided doses; increase dose in increments only after 3–7 days if tolerated. Use the lower end of the renal-based table when age-related creatinine decline or low muscle mass complicates interpretation of serum creatinine–calculate creatinine clearance rather than relying on serum creatinine alone.

Obtain baseline serum creatinine and calculate CrCl before initiation; reassess within 1–3 months after starting or changing dose and then every 6–12 months or sooner if clinical status changes. If renal function falls, reduce dose promptly according to the table or extend dosing interval.

Watch for dizziness, somnolence, confusion, unsteady gait, and peripheral edema; reduce dose by 25–50% or hold treatment for moderate to severe central nervous system effects or progressive renal impairment. For suspected overdose with severe CNS depression, obtain serum pregabalin level if available, support airway/breathing, and consider hemodialysis–pregabalin is substantially removed by dialysis and post‑dialysis supplemental dosing is required.