Lyrica

[Iamnew2]

Hi Neurology friends - I wanted to inquire the following. How often are you all prescribing Lyrica 600mg and if and so you do, for what conditions?
I have seen a trend of mostly non-Neuro docs prescribing exhorbitantly high doses of Lyrica and wanted to see what you all thought.

Thanks!

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[DrSatan]

Examples of conditions you're seeing it used for?

 

[Iamnew2]

Examples of conditions you're seeing it used for?

Well for example, one patient came on 300mg BID - to me that's extraordinarily high of a dose, and when I tried to go down patient says "My neurologist prescribed me 600mg" - he has neuropathic pain from a botched surgical intervention.

Some other patient that simply had a BKA which I have now taken over management - the FM/Medicine physician/midlevel randomly increased their dose from 150mg to 600! I almost stroked out.

I have never seen anyone prescribe such extraordinarily high doses. Some of the local primary care doctors also are prescribing Lyrica and gabapentin together or gabapentin PRN! I find all of this insane?

 

[DrSatan]

I don't prescribe much Lyrica but the maximum dose from what I can see is about 600 mg/day. If people tolerate it at that high of a dose & need further pain control, I could see how someone would push that dose if it works for the patient.

 

[Thama]

I rarely use Lyrica, but non-neurologists routinely have irrational fears of high doses of gabapentin. I regularly see people whose PCP gave them 100 mg BID of gabapentin for severe neuropathic pain, and when that doesn't work, call it a treatment failure rather than uptitrating to a non-homeopathic dose. Some people need that 900-1200 QID of gabapentin, and the same is probably true of high doses of Lyrica.

Re: Lyrica + gabapentin - this makes little sense conceptually, but IIRC there is some data on them being synergistic when given together, plus nobody really knows how either works mechanistically. So it's crazy, but not crazy. Gabapentin PRN, however, is straight bonkers.

 

[deathmerchant]

Hi Neurology friends - I wanted to inquire the following. How often are you all prescribing Lyrica 600mg and if and so you do, for what conditions?
I have seen a trend of mostly non-Neuro docs prescribing exhorbitantly high doses of Lyrica and wanted to see what you all thought.

Thanks!

That is indeed a high dose, although in neurology we do tend to stretch the few options we have sometimes. Lyrica and gabapentin have very wide therapeutic window. That being said, I have never prescribed more than 200 BID or 150 TID of Lyrica. Or 900 TID/800 QID of Gabapentin.

 

[adiradirim]

600mg per day is the max FDA recommended dose, and it comes in 300mg capsules, so 300mg BID is reasonable. I don't see anything concerning about that dose assuming there are no side effects. Going above that is probably pointless.

Prescribed for pain conditions including neuralgias, neuropathy, CRPS, and fibromyalgia/pain amplification syndromes.

 

[xenotype]

Yes going to 300mg BID in a patient with normal renal function, no other sedating medications (no benzos/opiates/other garbage) would be reasonable for neuropathic pain. Max dose gabapentin (1200mg TID or 900mg QID) also is reasonable. Gabapentin prn makes no sense. Long term combining gabapentin and lyrica makes no sense, but short term cross titration is reasonable when switching one to the other at high doses.

In terms of indications especially at high doses- I leave 'fibromyalgia' up to PCP/pain/rheumatologist as it is not a neurologic problem that I am going to manage. I would primarily use it for clear neuropathic pain (small fiber neuropathy (most commonly diabetic obvs), chronic painful mononeuropathy such as a old traumatic lesion, radiculopathy, post herpetic neuralgia, TG/atypical facial pain). I use it only after cymbalta and gabapentin at high doses didn't help and people already tried topical creams if appropriate. I wouldn't recommend it for 'back pain' or 'neck pain' that is not clearly radicular.

 

[Iamnew2]

Yes going to 300mg BID in a patient with normal renal function, no other sedating medications (no benzos/opiates/other garbage) would be reasonable for neuropathic pain. Max dose gabapentin (1200mg TID or 900mg QID) also is reasonable. Gabapentin prn makes no sense. Long term combining gabapentin and lyrica makes no sense, but short term cross titration is reasonable when switching one to the other at high doses.

In terms of indications especially at high doses- I leave 'fibromyalgia' up to PCP/pain/rheumatologist as it is not a neurologic problem that I am going to manage. I would primarily use it for clear neuropathic pain (small fiber neuropathy (most commonly diabetic obvs), chronic painful mononeuropathy such as a old traumatic lesion, radiculopathy, post herpetic neuralgia, TG/atypical facial pain). I use it only after cymbalta and gabapentin at high doses didn't help and people already tried topical creams if appropriate. I wouldn't recommend it for 'back pain' or 'neck pain' that is not clearly radicular.

Agreed! I use Gabapentin at high doses particularly for neuropathic pain, andI find that in the right dosing most people do well, I see the Gabapentin PRN and think why would anyone dose it this way, as you mentioned makes no sense. I also see PCPs do 100mg TID and then say "oh it didn't work!" and I think - they are under dosed that's why it probably "didn't work" and then these people are put on insane amounts of opioids - ie - oxygen 20mg 6 times daily, etc. blows my mind! I had one patient where the primary care doctor went from 150mg to 600mg over - and they were already on other pain and sedating type meds - but your post essentially confirms my thoughts on these meds. I use Lyrica but I don't use it at 600mg - I find it that if someone didn't have good results on max gabapentin 3600mg, maxing out on insane amounts of Lyrica isn't going to help and most patients get super sedated. thanks for your post!