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Switching between gabapentin and pregabalin for neuropathic pain; Robertson K, Marshman LAG, Plummer D, Downs E. Effect of Gabapentin vs Pregabalin on Pain Intensity in Adults With Chronic Sciatica: A Randomized Clinical Trial. JAMA Neurol. 2019 Jan 1;76(1):28-34. doi: 10.1001/jamaneurol.2018.3077. Erratum in: JAMA Neurol. 2019 Jan 1;76(1):117. pregabalin dose and titrating up the gabapentin dose. Pregabalin total daily dose pre-switch Gabapentin total daily dose post switch (Toth study8) Suggested daily dose of gabapentin 150mg 900mg 300mg tds 225mg 901mg to 1500mg 400mg tds 300mg 1501mg to 2100mg 2x300mg tds 450mg 2101mg to 2700mg 2x400mg tds and 7.7 for pregabalin (6.5–9.4), and are dose-related.2 Switching from gabapentin to pregabalin may be considered for effi cacy or tolerability reasons. Although there is no clear evidence that either gabapentin or pregabalin is more effective than the other for neuropathic pain,1 patients may bene-fi t from switching. In an open-label study, Offer one of the other three remaining drug options (for example if on amitriptyline, switch to duloxetine, gabapentin, or pregabalin). If the treatment is still not effective or is not tolerated, consider switching again until a suitable treatment is found, or all four drugs have been tried. Previously, studies have shown 6:1 conversion factor, from gabapentin to pregabalin. (Pain Med. 2011 Jul;12(7):1112-6.) The Literature: Am J Ther. 2013 Jan;20(1):32-6.* Compared unidirectional switch from gabapentin to pregabalin with two rotation strategies: 1. Direct switch o Stop gabapentin, initiate pregabalin at next scheduled dose period N.B. Concurrent use of gabapentin and pregabalin is not funded. 15. For information on alternative medicines for neuropathic pain, see: nzf.org.nz/nzf_2556#nzf_70735. If treatment has been ineffective or adverse effects are intolerable, gradually discontinue pregabalin or gabapentin and/or switch to an alternative medicine. 17 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 switch: conversion from Humalog is 1:1 Regulatory standards prevent pharmacists from directly substituting Admelog for Humalog, so prescriptions will need to be written specifically for Admelog. Lyrica Gabapentin: An Easy Switch! Testosterone Formulations s significant variation in the costs of strength, duration of use, and product 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) If considering switching a patient from Gabapentin to Pregabalin, or vice-versa, the following equivalence is suggested with Pregabalin roughly six times more potent than Gabapentin: Total daily dose of Gabapentin Total daily dose of Pregabalin Pregabalin or Gabapentin (note 1) Switch to the one which was not used first (gabapentin or pregabalin) if not tolerated Dose Titration Notes Pregabalin Initially 150mg in 2-3 divided doses. Max. 600mg daily Aim for twice a day dosing with pregabalin (benefit cost and compliance). maximum of 600mg/day after (150mg bd - £12.12) see appendix 1 Daily Dose of gabapentin pre-switch (mg/day) 0-900 Daily dose of pregabalin per day post switch (mg/day) Dosing schedule of pregabalin 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 of gabapentin falls from 60% to 33% as the total daily dosage increase from 900mg to 3600 mg. For safety reasons the Nottinghamshire APC guideline recommends that the maximum daily dose of gabapentin should NOT exceed 1800mg. Gabapentin in renal impairment (ref: Neurontin SPC): Creatinine Clearance (ml/min) Dose ≥80 300mg TDS to 600mg TDS Ensure that gabapentin and pregabalin are prescribed at an appropriate place in therapy for neuropathic pain taking into consideration value for money. Ensure prescribed (and taken) doses of pregabalin and gabapentin are not outside the therapeutic dose range. Prescribing of pregabalin capsules should be optimised to the This may include switching between the gabapentinoids: gabapentin and pregabalin. Considerations before switching. Consider the following points before switching and consult local policy if available. Evidence base. There is no consensus or national guidance on how to switch. The evidence base on switching between gabapentinoids is limited because: replace gabapentin 600mg three times a day with pregabalin 200mg twice a day replace gabapentin 900mg three times a day with pregabalin 200mg twice a day (Note: switch to pregabalin 200mg twice a day is recommended from both 600mg and 900mg three times a day of gabapentin). The dose of pregabalin can be further increased Cross tapering from gabapentin to • When cross tapering from gabapentin pregabalin or gabapentin duloxetine, the dose of gabapentin should be reduced by 300mg every 4 days until patient is on 300mg three times daily. • Gabapentin dose should continue to be withdrawn, whilst commencing 3rd line treatment (see page 3 for further We would like to show you a description here but the site won’t allow us. Switch (mg/day) Daily Dose of Pregabalin Post-Switch (mg/day) (Using Twice Daily Dosing) 0–900 150 901-1500 225 1501-2100 300 2101-2700 450 2700 or higher 600 Another small study of 32 patients with post-herpetic neuralgia examining the outcomes of changing from gabapentin to pregabalin was carried out by Ifuku et al.9 For the purpose of Both transition designs were studied at 3 dosage levels: gabapentin 900 mg/d to pregabalin 150 mg/d, gabapentin 1800 mg/d to pregabalin 300 mg/d, and gabapentin 3600 mg/d to pregabalin 600 mg/d. Overall drug exposure achieved during the 2 transition designs was the sum of the gabapentin and pregabalin concentrations, expressed as pregabalin
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