Clarify Risks and Benefits of Gabapentin and Pregabalin

Rxs for gabapentin and pregabalin (Lyrica) will continue to surge...possibly driven by the search for non-opioid options for pain.

Gabapentin is now the tenth most commonly prescribed med in the U.S. Lyrica ranks eighth in drug spending.

Consider gabapentinoids from all angles before recommending them.

Weigh evidence. Think of gabapentinoids as a preferred option for neuropathic pain...such as postherpetic neuralgia or diabetic neuropathy.

In these cases, efficacy seems similar to SNRIs. Tricyclics may be more effective...but come with their own side effects and CV concerns.

Evidence varies for other gabapentinoid uses. For example, they're alternatives for fibromyalgia pain or some anxiety disorders.

But there isn't good evidence for use in chronic back pain. And don't go to gabapentinoids for sciatica...they aren't better than placebo.

Discourage COMBINING gabapentin and pregabalin. There's no good evidence this works better or has fewer side effects than either alone.

Consider risks. Misuse and abuse are a growing concern. For example, high gabapentinoid doses may cause mild euphoria...and patients with substance use disorder are at higher risk of abusing these meds.

In fact, gabapentin is now Kentucky, Tennessee, and West Virginia. Expect other states to follow suit.

Watch for red flags...early refills, multiple prescribers, etc.

Continue to educate about gabapentinoid side effects...dizziness, drowsiness, peripheral edema, etc. And caution that combining a gabapentinoid with an opioid may increase the risk of overdose death.

Compare products. Lyrica CR is dosed once daily and costs up to $800/month...Lyrica is often BID and costs $500. But TID gabapentin costs as little as $40/month. Watch for generic pregabalin in July 2019.

Check dosing. Suggest starting low and titrating weekly, or more often if tolerated, to usual effective doses. This can take weeks...but pregabalin titration may be faster since its target range isn't as wide.

For example, suggest aiming for gabapentin 1,200 to 3,600 mg/day or pregabalin 300 to 600 mg/day for neuropathic pain.

Recommend tapering doses over at least a week when stopping.

See our new chart, Comparison of Gabapentin and Pregabalin, for more about uses, risks, and dosing of these meds.

Key References

  • JAMA Intern Med 2018;178(2):292-4
  • N Engl J Med 2017;377(5):411-4
  • PLoS Med 2017;14(10):e1002396
  • Medication pricing by Elsevier, accessed Jul 2018
Pharmacist's Letter. Aug 2018, No. 340801

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