Switching pregabalin to gabapentin in patients with normal ...



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Pregabalin Review – Dosing Information

This information has been produced to assist practices who are reviewing pregabalin as part of the Incentive Scheme

Switching pregabalin to gabapentin in patients with normal renal function

This would be a straight switch, rather than titrating down the pregabalin dose and titrating up the gabapentin dose.

|Pregabalin total daily dose pre-switch |Gabapentin total daily dose post switch (Toth |Suggested daily dose of gabapentin |

| |study9) | |

|150mg |900mg |300mg tds |

|225mg |901mg to 1500mg |400mg tds |

|300mg |1501mg to 2100mg |2x300mg tds |

|450mg |2101mg to 2700mg |2x400mg tds |

|600mg |2701mg to 3600mg |3x300mg tds |

For daily doses of pregabalin below 150mg daily, e.g. 100mg, 75mg – switch to gabapentin 100mg tds, and titrate up if necessary (see gabapentin titration schedule below on p2).

Gabapentin dose adjustment based on renal function

Discontinuing gabapentin

If gabapentin has to be discontinued it is recommended this should be done gradually over a minimum of 1 week (SPC).

Stepping down and discontinuing pregabalin

The SPC for Lyrica states that pregabalin should be discontinued gradually over at least one week, independent of the indication.

NHS Gloucestershire recommends reducing the dose by 50-75mg per week

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Suggested withdrawal schedule for a dose of 150mg bd (based on table from above reference):

| | Week 1 | Week 2 | Week 3 | Week 4 | Stop and |

| | | | | |review |

| | | | | |patient |

| Morning | 150mg | 75mg | 150mg | 25mg | |

| Evening | 75mg | 75mg | 50mg | 25mg | |

Gabapentin Titration Schedule

Gabapentin can be given with or without food and should be swallowed whole with sufficient fluid-intake (e.g. a glass of water).

Standard schedule

| | Day 1 | Day 2 | Day 3 | Day 4 | Day 5 |

| Morning | | 300mg | 300mg | 300mg | 300mg |

| Midday | | | 300mg | 300mg | 300mg |

| Night | 300mg | 300mg | 300mg | 300mg | 600mg |

| | Day 6 | Day 7 | Day 8 | Day 9 | Day 10 |

| Morning | 300mg | 300mg | 300mg | 600mg | 600mg |

| Midday | 300mg | 600mg | 600mg | 600mg | 600mg |

| Night | 600mg | 600mg | 600mg | 600mg | 600mg |

Accelerated schedule

| | Day 1 | Day 2 | Day 3 |Day 4 | Day 5 |

| Morning | 300mg | 300mg | 300mg | 300mg | 300mg |

| Midday | 300mg | 300mg | 300mg | 300mg | 600mg |

| Night | 600mg | 300mg | 600mg | 600mg | 600mg |

| | Day 6 | Day 7 | Day 8 | Day 9 | Day 10 |

| Morning | 300mg | 600mg | 600mg | 600mg | 600mg |

| Midday | 600mg | 600mg | 600mg | 600mg | 600mg |

| Night |600mg | 600mg | 600mg | 900mg | 900mg |

Based on individual patient response and tolerability, the dose can be further increased in 300 mg/day increments every 2-3 days up to a maximum dose of 3600 mg/day. Slower titration of gabapentin dosage may be appropriate for individual patients. The minimum time to reach a dose of 1800 mg/day is one week, to reach 2400 mg/day is a total of 2 weeks, and to reach 3600 mg/day is a total of 3 weeks1.

Elderly patients (over 65 years) and patients with compromised renal function may require dosage adjustment because of declining renal function.

Somnolence, peripheral oedema and asthenia may be more frequent in elderly patients.

Price comparison Table (April 2013 Drug Tariff)

|Drug and dose |Cost for 28 days |Cost per year |

|Gabapentin 100mg tds |£2.12 |£27.56 |

|Gabapentin 300mg tds |£2.90 |£37.70 |

|Gabapentin 400mg tds |£3.79 |£49.27 |

|Gabapentin 600mg tds |£9.41 |£122.33 |

|Gabapentin 2x300mg tds |£5.80 |£75.40 |

|Gabapentin 800mg tds |£33.21 |£431.73 |

|Gabapentin 2x400mg tds |£7.58 |£98.54 |

|Pregabalin 25 or 50 or 75 or 100 or 150 or 200 or 225 or 300mg bd |£64.40 |£837.20 |

|Pregabalin 25 or 50 or 75 or 100 or 150 or 200mg tds |£96.60 |£1255.80 |

References

1. An update on the drug treatment of neuropathic pain Part 1 DTB 2012; 50(10): 114-7

2. An update on the drug treatment of neuropathic pain Part 2 DTB 2012; 50(11): 126-9

3. Moore RA et al. Gabapentin for chronic neuropathic pain and neuralgia in adults. Cochrane database of systematic reviews 2009, Issue 3

4. Moore RA al. Pregabalin for acute and chronic pain in adults. Cochrane 2011, Issue3

5. Wirral Clinical Guideline for the management of neuropathic pain

6. NHS choices

7. eMC Neurontin SPC Accessed 5.3.13

8. UKMi Q&A 408.1 How do you switch between pregabalin and gabapentin for neuropathic pain, and vice versa? 2012

9. Toth C Substitution of gabapentin therapy with pregabalin therapy in neuropathic pain due to peripheral neuropathy. Pain Medicine 2010; 11:456-465

10. NICE Clinical Guideline 66 The Management of Type 2 Diabetes

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Creatinine Clearance

(ml/min) or eGFR |Total Daily Dose

(mg/day)

| |e"80

|900-3600 | |50-79

|600-1800 | |30-49

|300-900 | | 15-29

|*150-600 | | ................
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