Monday, June 3, 2013
Lyrica: A Program to Gradually Get Used To This Neuropathic Drug
Lyrica (pregabalin) is one of the main drugs used in neuropathic pain. Neuropathic pain is pain from nerves, it is probably/is the worst of all pain, and the patients truly suffer with this type of pain. The pain, when originating in the nerves, have a direct path to the brain heightening the pain syndrome. Lyrica, like Neurontin (gabapentin) works to stop the flow of the nerve stimulus to the brain quite differently than opioids, and without the addictive qualities. Lyrica is normally twice daily, but can be used 3 times daily, and has a maximal dose of 300 mg per day. Below is a typical gradual process of getting use to the drug, although many go much faster. The side-effect of drowsiness is more prevalent as you get use to the drug in the lower doses than at the higher doses. Typically, if I can ease the transition onto the drug gradually, my patients can avoid much of the side effects. The AM dose should be done around 7 am and the PM dose as soon as you get home in the evening for good (latest 7 pm if you arise between 6-7 am). It is a 12 hour drug and you want the PM dose to be out of your system when you have to function in the morning.
Week I (weeks can be changed into 4 day periods): No AM dose 25 mg PM
Week II: No AM dose 50 mg PM
Week III: No AM dose 75 mg PM
Week IV: 25 mg AM 50 mg PM
Week V: 25 mg AM 75 mg PM
Week VI: 25 mg AM 100 mg PM
Week VII: 50 mg AM 75 mg PM
Week VIII: 50 mg AM 100 mg PM
Week IX: 50 mg AM 125 mg PM
Week X: 75 mg AM 125 mg PM
Week XI: 75 mg AM 150 mg PM
Week XII: 100 mg AM 150 mg PM
Week XIII: 125 mg AM 150 mg PM
Week XIV: 150 mg AM 150 mg PM
Of course there are many versions of this. At times, based on symptoms and symptom relief you stay at a certain level. Each new level requires time to see how it is helping the overall neuropathic pain. Since most of your healing of this problem, like so many other problems, occurs at night during REM sleep, the medication dosing until the last level is always more during the evening. Dosing like this one requires an initial RX of 25 mg to see if you can coexist with the drug, then soon after, two more prescriptions of 25 mg and 50 mg that you can mix and match to get the right dose.
The goal of all this is to find a level of drug that reduces the neuropathic pain to a level 0-2 consistently. Whatever level that is, you stay at that level for typically 3 months, and then you gradually, every 4 days, go backwards down the slide. If you get to a level and the symptoms flare, go back up 2 levels and stay there for several weeks, and try to go down again. There are many versions of all this.
You can see quite easily that making a decision to use this drug is quite a committment. If you get to the highest level, or the highest level you can tolerate without adequate pain relief, it is common to add other drugs to the mix. For those patients who can not tolerate Lyrica, Neurontin can be tried. Some patients respond more to one than the other.
I hope this has been helpful. Lyrica has been a wonderful drug for so many of my patients, but getting on and off can be such a challenge that many patients stop taking it. It is common for patients to be started at 75 mg twice daily, and have such a bad experience, that the drug is stopped unnecessarily. This is an option to an easier way to get used to the drug.