Expert Panel Publishes Recommendations for Pregabalin in Neuropathic Pain

An expert international team of chronic pain specialists have published evidence-based recommendations on dosing and titration of pregabalin for neuropathic pain in primary care, with an emphasis on optimizing individualized dosing protocols to improve adherence to therapy. The recommendations were published in Postgraduate Medicine.

Nonadherence to first-line pregabalin, which involves both patient- and clinician-related factors, remains a common challenge in successfully using the drug to treat neuropathic pain. Patient perception, such as the fear that high doses of pain medication can lead to side effects and addiction, can stand in the way of proper dosing and adherence to therapy.

Clinicians can address patient concerns in a follow-up visit after administering a prescription. A plain-language review of possible side effects with patients as well as a discussion on patient monitoring may ease fears by helping patients feel more informed about their treatment plan.

In terms of initial dosing, prescribing information for pregabalin in the setting of neuropathic pain recommends starting at 150 mg divided into 2 or 3 equal doses per day. Clinicians can then increase this dose to 300 mg/day divided into 2 doses after 3 to 7 days. If appropriate, clinicians can also further increase dosing to a maximum of 600 mg/day the following week.

The expert panel suggests that based on their clinical experience, patients who begin pregabalin at 150 mg/day can develop side effects early, which may increase the risk of discontinuation. To circumvent this issue, the panel recommends starting pregabalin at a low dose, even as low as 25 mg/day (for older adults or frail patients) or 50 mg/day in the evening, followed by slow titration to a therapeutic dose.

Regular monitoring of tolerability is warranted during this treatment course. The panel adds that if the patient does seem to tolerate the therapy at these doses, the doses can then be incrementally up-titrated weekly until a maximum clinical response is achieved.

While doses are increased slowly, clinicians should also help patients manage expectations regarding therapy, as this may also improve overall adherence. Clinicians should continue to remind patients about possible side effects. In addition, clinicians should also clearly discuss with patients how a slow titration approach can optimize tolerability, help in monitoring side effects, and assist in finding the most appropriate and effective dose.

The expert panel concluded that “empowering patients with this knowledge while encouraging a ‘low and slow’ approach should help them determine the optimal titration tempo for their individual therapeutic needs.”

Disclosure: This clinical trial was supported by Pfizer. Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Freynhagen R, Baron R, Kawaguchi Y, et al. Pregabalin for neuropathic pain in primary care settings: recommendations for dosing and titration. Postgrad Med. 2021;133(1):1-9. doi:10.1080/00325481.2020.1857992