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2. Cross-taper: A pharmacokinetic simu-lation model compared a stop/start approach with a four-day cross-taper whereby 50% of the gabapentin dose and 50% of the target pregabalin dose is given for four days, followed by discontinuation of gabapentin and use of target dose of pregabalin.5 Both approaches were pharmacokinetically comparable. 3. o Stop gabapentin, initiate pregabalin at next scheduled dose period Cross-taper Co-administer 50% of gabapentin dose + 50% of desired pregabalin dose for 4 days o Discontinue gabapentin after day 4 and increase pregabalin to target dose after day 4 Transitioning patients from gabapentin to pregabalin could be achieved by either approach Cross-tapering. This method is described in the literature. How to conduct cross-tapering. prescribe half the dosage of the initial medication along with half an equivalent dosage of the replacement medication for two to four days (1) Unfortunately there is no perfect dose equivalent of gabapentin to pregabalin. Some have suggested 300mg of gabapentin to 50 mg of pregabalin, but I also want to remind you of the dose dependent kinetics of gabapentin. Two different gabapentin to pregabalin transition designs were simulated based on their respective population pharmacokinetic profiles. The first design involved immediate discontinuation of gabapentin therapy with initiation of pregabalin therapy at the next scheduled dose period. This retrospective cohort study was performed to describe and evaluate strategies for rotation. Patients rotated while admitted from June 1st, 2014 to April 25th, 2020 at a large, academic medical center were included. The primary outcome was the proportion of rotations using a direct switch strategy compared to a cross-taper strategy. Tapering: You don’t need a long taper since they work similarly, but a short overlap helps. Reduce Gabapentin while starting Pregabalin low and increasing gradually. Dosing: Starting at 75mg and titrating up is the safest move. Pregabalin absorbs better, so jumping straight to 200mg might hit too hard. Give your body time to adjust. Analgesic Tapering Guidelines for adult patients with persistent pain patients taking strong opioids and/or gabapentinoids. Prescribing of gabapentinoids for neuropathic pain should be reviewed in line with the criteria set out in NICE4 and should be gradually discontinued if ineffective. 2. Cross-taper: A pharmacokinetic simu-lation model compared a stop/start approach with a four-day cross-taper whereby 50% of the gabapentin dose and 50% of the target pregabalin dose is given for four days, followed by discontinuation of gabapentin and use of target dose of pregabalin.5 Both approaches were pharmacokinetically comparable. 3. Cross-taper: A pharmacokinetic simulation model compared a stop/start approach with a four-day cross-taper whereby 50% of the gabapentin dose and 50% of the target pregabalin dose is given for four days, followed by discontinuation of gabapentin and use of target dose of pregabalin.5 Both approaches were pharmacokinetically comparable. 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. Stop/start approach with a 4-day cross-taper: give 50% of the pregabalin dose and 50% of the target gabapentin dose for 4 days, then discontinue pregabalin and initiate target dose of gabapentin, also based on a simulation study [Citation 69]; 3. Taper down pregabalin and then gradually up-titrate gabapentin. 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. Divide total daily dose (in mg) of gabapentin by 6 to give total daily dose of pregabalin (in mg). 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 There are no validated dose conversions between gabapentin and pregabalin due to differences in pharmacokinetics and varying efficacy seen in studies. However, some authors have proposed dose conversions based on these parameters (see Tables 1 and 2). One switching method suggests daily doses of gabapentin between 901 to 1,500 mg/day should be converted to pregabalin 225 mg/day in two divided Key E Taper and stop original drug then wait 24 hours to start the start new drug A Cross taper cautiously F Taper and stop original drug then wait 24 hours to start the start new drug at low dose B Cross taper cautiously and start new drug at low dose G Taper and stop original drug then wait ** period of time ** to start the start new drug Daily Dose of Daily dose of pregabalin per day Dosing schedule of pregabalin gabapentin pre-switch post switch (mg/day) (mg/day) 0-900 150 75mg twice daily From the National Electronic Library for Medicines. www.nelm.nhs.uk 1 Medicines Q&As 901-1500 225 75mg in the morning and 150mg in the evening* 1501-2100 300 150mg twice daily 2101-2700 450 The available data suggests that transitioning patients from gabapentin to pregabalin can be done using an overnight switch, or using a cross-taper approach. Based on ease of an overnight switch, this will be the best option in the case of most patients. Importantly, however, the efficacy and safety of these approaches has not been established. Gabapentinoid suggested tapering regimes 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 But in terms of turning off chronic neurontin in favor of the apparently more favorable (in my experience thus far) pregabalin, I'm seeing some neurologists replace a gabapentin dose for a pregabalin, or do more traditional cross tapers.
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