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Monday, October 15, 2012

Pregabalin and Gabapentin for Neuropathic Pain and CRPS

Pregabalin and Gabapentin for Neuropathic Pain and CRPS

 
By Brett R. Stacey, MD, and Pamela Campbell, MD
Comprehensive Pain Center, Oregon Health & Science University, Portland, Oregon

Recently, pregabalin (Lyrica®) was approved by the Food and Drug Administration (FDA) for the treatment of post herpetic neuralgia (PHN) and painful diabetic peripheral neuropathy (DPN). Pregabalin has a chemical structure similar to gabapentin (Neurontin®), a medication originally developed to treat seizures that is now widely used to treat many varieties of neuropathic pain including CRPS. Both medications reduce pain by normalizing overactive pain pathways. Pregabalin is the first drug ever approved in the United States for two different neuropathic pain conditions. We believe it will be an important treatment option for many patients with CRPS. 

Gabapentin has been a great advance in treating CRPS and neuropathic pain. In addition to its effectiveness, it is very safe, with no reports of fatal overdose or organ failure. However, it does not work for everyone and sometimes the side effects are very bothersome. Does pregabalin offer an improvement?
There are currently at least six large studies with pregabalin for the treatment of PHN and DPN. In these studies pregabalin shows up to a 50 percent decrease in pain scores. This is better than the roughly 30 to 40 percent reduction in pain scores observed in the trials of gabapentin for the same indications. In addition to pain relief, patients treated with pregabalin report improvements in sleep, mood, and day-to-day function. Because of its longer half-life, pregabalin can be dosed on a twice a day schedule. (Gabapentin is dosed three times a day.) At high doses, much of the gabapentin is never absorbed from the bowel, whereas pregabalin is easily absorbed at all doses, making for more predictable dosing. Data suggest that pregabalin can begin reducing pain as quickly as one day after it has been started. This is quicker than ever reported with gabapentin. Finally, preliminary results from a study of patients with neuropathic pain who had not responded to gabapentin and two other medicines shows that even in those patients, pregabalin can provide significant relief. The majority of patients in this study (who had PHN and DPN) strongly preferred pregabalin to gabapentin.

In addition to neuropathic pain, pregabalin has been shown to be effective in fibromyalgia pain, the pain after spinal cord injury, and anxiety. 

Pregabalin comes in 8 dosage strengths from 25mg up to 300mg. All capsule sizes are the same price Roughly 1,800 mg of pregabalin is approximately $90, while pregabalin twice a day for all doses is around $118.

Gabapentin and pregabalin have similar side effects. The most common are dizziness and sedation. Patients placed on gabapentin usually experience side effects as they titrate slowly up to an effective dose, which is roughly 1,200 to 3,600 mg per day. Conversely, for patients taking pregabalin the typical starting dose of 150 mg per day can be helpful.. The range of effective doses is 150 to 600mg per day. For both medications, side effects tend to decrease over time. Less common side effects include peripheral edema and weight gain especially when taken in combination with oral hypoglycemics.

Pregabalin is categorized by the FDA as a schedule V drug, the lowest level of surveillance from the FDA. This means it is a controlled substance.

The earliest reports of gabapentin's use in treating pain were case reports of a few patients with CRPS who improved with gabapentin. Unfortunately, there have never been larger, controlled studies that definitively prove the benefits of gabapentin. As of yet, there are no studies in CRPS for pregabalin. CRPS and all other nerve pathology other than PHN and DPN are considered off label since studies in nerve pain have only been done in these specific conditions. 

Our clinical experience
Here at Oregon Health & Science University, we have 8 years of research experience with pregabalin and since September of 2005 many of our patients have received it. Almost every patient converted to pregabalin from gabapentin prefers pregabalin either because of improved pain control or fewer side effects. Some patients have pain relief immediately. As everyone reading this knows, treating neuropathic pain is challenging, so pregabalin certainly doesn't work for everyone. Our experience coupled with the extensive research supporting its use in other painful conditions makes us optimistic that pregabalin will prove to be a valuable tool in treating CRPS.
Updated August 14, 2006
 

8 comments:

  1. My husband, who I run this blog for, tried Lyrica, some 4 1/2 yrs ago or so and it gave him horrific nightmares. So much so he would try to not fall asleep. Thank God they took him off of it! But he also takes gabapentin, and I take gabapentin for neuropathy. It works for me, it doesnt take all the pain away, but it does work and its a noticable difference. For my husband, he can only take 900 mg a day because anymore and he has side affects. We live in a medical marijuana state and I would love him to be able to try this but his doctors tell him that if he does they will cut him off his meds. He tried methadone, caused bladder problems. He has several medications but the 2 main pain meds are morphine and dilaudid. Anyway, he has an appointment with his pain doctor nov 6th, Im going to ask her if he can give pregabalin a try. Thank you for posting and discussing it. :o) Have a healthy day!

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    1. Hello Dennis- Yeah, I guess including my own experience would have helped: I attempted this to be began at 75mg TID, imcrease by 75mg every 3 days until well, 600mg per day.. Prior authorization even to get it-and since a C-IV, I pretty much got myslf also on some sick-o's radar. And the side effects I had suffered were intolerable: they had me on way too much-and before even the RSD got as bad as it is currently: I simply did not do well. Even at the LOWEST prescribed dose no relief was obtained and well, I was told to keep taking it. Falling asleep at the computer as I am taking 2 hours to get a 1 paragraph email: I have taken other meds labeled "dangerous" and not to say this is: I have a good friend who had to put through an ICU stay from a reaction to Neurontin: so I was finally switched to a currently somewhat helpful combo of Dilantin/Keppra-and though not ideal, Dilantin works siilar they said as Tegretol. Amd since it helps-great...

      What bothers me remains the unequal access to at least potentially effective treatments that would benefit many-and yet because fibro is not my diagnosis, I could get it now: it simply delayed treatment

      New policy has helped that-so I hope that the next day is going to be better.

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  2. I have been taking gabapentin and it has been helpful in managing pain post nerve block. That said, the block is 9 months old and has begun losing effectiveness though the gabapentin seems to have helped to prolong its effects.

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    1. RSD-I am glad to hear you have gotten some relief from the gabapentin. Congratulations-any victory is a sweet one.

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