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Pregabalin and gabapentin should only be prescribed where there is evidence of neuropathic changes / neuropathic pain, and even then 50% of patients will not get any benefit at all. Prescribing of gabapentinoids for neuropathic pain should be reviewed in line with the criteria set out in NICE CG173 for neuropathic pain Consider the potential for misuse or illicit diversion before prescribing pregabalin, gabapentin or tramadol. Patients should be told about the risk of abuse and dependence. Tramadol has limited position for acute use. NICE do NOT advice use of long-term tramadol unless advised by specialist. There is no established guidance on the conversion of gabapentin to pregabalin or vice versa. Thus, firm recommendations cannot be made. Pregabalin to gabapentin dose equivalence calculation. using the 6:1 ratio an equivalent dose of gapapentinoid can be determined using a step-wise approach; determine total dose (in mg) taken by an individual in a 24-hour period; multiply total daily dose (in mg) of pregabalin by 6 to give total daily dose of gabapentin (in mg) gabapentin alone, combination therapy of amitriptyline and gabapentin should be considered. Pregabalin (Anticonvulsant) Within NHS Tayside pregabalin may be used in patients who have not achieved adequate pain relief from, or did not tolerate, first and second line drug treatments. Pregabalin can be used in combination with a tricyclic gabapentin and pregabalin, are not effective for many people but have significant potential for harm and misuse 7-9. There are reports of an increasing street value, and cases of dependency have been described 10-12. Evidence also highlights that over recent years, whilst the overall number of drug-related deaths has slightly reduced, who think they might obtain benefit from the use of a pregabalin or gabapentin should undertake a trial dose reduction periodically, to ensure they are benefiting / to see if they get the same benefit on a lower dose. TCAs with gabapentin, pregabalin and commonly used antidepressants Amitriptyline or nortriptyline (at doses recommended in this guideline) may safely be added to the following: • Gabapentin (increased risk of hyponatraemia). • Pregabalin • Citalopram 20 mg PO daily (increased risk of hyponatraemia) Opioid dose conversion chart, syringe driver doses, rescue/PRN doses and opioid patches. Use the conversion chart to work out the equivalent doses of different opioid drugs by different routes. Source: yorkhospitals.nhs.uk; Clinical Resource: Chart; Register to Access Content: No MHRA advises prescribers to show caution when initiating gabapentin or pregabalin and consider whether adjustments in dose or dosing regimen are necessary in patients at higher risk of respiratory depression, including those: NHS_England_pregabalin_and_gabapentin_advice_Dec_2014.pdf From 1st April 2019, gabapentin and pregabalin will be reclassified as Schedule 3 controlled drugs under the Misuse of Drugs Regulations 2001. 2. Aim The principal aim of these guidelines is to provide additional information to enable non Gabapentin and pregabalin both require dose adjustment in individuals with reduced renal function. Consult the summary of product characteristics (SmPC) for gabapentin and pregabalin for further information before determining an equivalent dose and switching strategy. An open label study substituted gabapentin with pregabalin in patients with neuropathic pain due to peripheral neuropathy. The author describes an overnight switch from gabapentin to pregabalin, based on a conversion table which is described in the paper as “of the author’s creation” (table 1). The dose conversion used was gabapentin 3600 mg/day to pregabalin 600mg/day, gabapentin 1800 mg/day to pregabalin 300mg/day and gabapentin 900 mg/day to pregabalin 150 mg/day. Adverse effects Adverse effects are common with gabapentinoids resulting in a discontinuation rate of at least 11%, but Gabapentin (Neurontin): risk of severe respiratory depression - GOV.UK 10. MHRA Drug Safety Update. Pregabalin (Lyrica): reports of severe respiratory depression. February 2021. Pregabalin (Lyrica): reports of severe respiratory depression - GOV.UK 11. Public Health England. Advice for prescribers on the risk of the misuse of pregabalin and Pregabalin is an alternative to gabapentin in patients who have not achieved adequate pain relief from, or have not tolerated, first and second line treatments. This drug can be used in combination Pregabalin to gabapentin dose equivalence calculation. using the 6:1 ratio an equivalent dose of gapapentinoid can be determined using a step-wise approach; determine total dose (in mg) taken by an individual in a 24-hour period; multiply total daily dose (in mg) of pregabalin by 6 to give total daily dose of gabapentin (in mg) An in-house pharmacokinetic simulation suggests that a regime of halving the original gabapentin dose, and introducing half the intended dose of pregabalin on day 0, then stopping gabapentin and doubling the pregabalin dose on day 4 leads to fairly stable drug levels of pregabalin equivalents. Several studies reviewing conversion of gabapentin to pregabalin predict that a rough ratio for conversion is about 6:1 gabapentin to pregabalin. In addition, a direct switch from gabapentin to pregabalin seems to be well tolerated, making the conversion simple. gabapentin, like Lyrica, does have abuse potential. This reinforces the importance of ensuring each patient taking gabapentin has an appropriate indication, dose and frequency to maximize benefit and avoid adverse events or misuse. Daily Dose of Gabapentin (mg/day) Daily Dose of Lyrica (mg/day) 0 – 300 50 301 – 450 75 451 – 600 100
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