x-titrating gabapentin and pregabalin

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Anasazi23

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How are you working it? Clearly, it might be done differently if one or the other might be an adjunctive epilepsy medication. 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. It becomes slightly more complicated when people are on these old, mountain doses of neurontin and you're considering the rare but possible withdrawal seizure. Then, I began to pharmacologically overthink it....in any event:

i.e.
Current meds:
Lexapro 30mg PO QD
Neurontin 800mg PO QID
Seroquel 200mg PO BID

How would you procede?

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Question, somewhat related.

What are your experiences with gabapentin & pregabalin in psychiatric DOs? Reason why I ask is most of the data I've seen for both meds is not very susbtantial. I'm not saying you're wrong to use it, just that you probably know something I don't & I'd like to learn more.
 
Question, somewhat related.

What are your experiences with gabapentin & pregabalin in psychiatric DOs? Reason why I ask is most of the data I've seen for both meds is not very susbtantial. I'm not saying you're wrong to use it, just that you probably know something I don't & I'd like to learn more.

I don't use pregabalin--it's just too expensive, and not prescribed much in our area except for chronic pain conditions, for which it does seem superior to gabapentin. I have patients on it, but they're usually getting it from a pain clinic, not from me.

I do use a fair amount of gabapentin, but I only really believe in it in 2 populations: pain which is truly neuropathic--e.g. shooting or burning pain in a neurologically reasonable location; and in alcoholics, where I think it really seems to repair the supression of endogenous GABA release to help with sleep, anxiety, and alcohol cravings in that critical post-detox/early recovery period. Even there, I present to the patient as a "trial"--and if it doesn't work, we quit.
 
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I'm not sure if the literature vs. "real" case based experience justifies non-use of most antiepileptic drugs (AEDs) in various types of cases. Outside of the addiction-specific literature, the truth is that randomized trials exclude most patients that are often the ones that wind up in our offices.

On that idea, I have used neurontin with surprising success for a select number of patients for either social anxiety, and in some cases, GAD and panic. I'm finding that pregabalin has an even better effect for patients as well - though the literature generally shows that it should be dosed within the 200-450mg range, and that effect size was insignificant below this dose range, and plateaued over that dosing range as well.

This metanalysis shows that there is a place for AEDs on either the mood/anxiety spectrum, and there is a great deal of literature on it's efficacy in both toleration of, for example, gabapentin in concomitant use with alcohol, and for withdrawal treatment.

I would make the same argument for other consistently vilified medications which get swept under the carpet as ineffective, such as buspar. It has decent augmentation power in the right patient. Many of my patients have a prior (or current) alcohol use problem, opiate addiction - either active or in remission, and remain with chronic anxiety that multiple SSRI trials have failed to adequately control. Needless to say anything about benzodiazepine treatment.

Some other articles I've come across:

http://www.ncbi.nlm.nih.gov/sites/e...med.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum
 
where I think it really seems to repair the supression of endogenous GABA release to help with sleep, anxiety, and alcohol cravings in that critical post-detox/early recovery period. E

I've thought the same as well, though I never found any literature to back it up. Only med I know of that's supposed to help out with alcohol cravings, using the glutamate angle is Campral, and the studies showing its effectiveness aren't that great IMHO.

From what I understand, although gabapentin is supposed to work similar to GABA, its actual effects may actually be due to other mechansims. Ouch, don't have the time to better research my response because I'm in the middle of work. I'll try to look into it more tonight.
 
Right...well, the chemical structure is different, but both lyrica and neurontin have gabaergic type effects - but neither are isomers or GABA itself. The mechanism of course is that of binding to voltage-gated calcium channels - not by acting on GABA or modulating GABA itself.


Here's a representation of the three formulations:

http://www.lyricapro.com/cwpb/appma...Label=lyrica_epi_pro_frequentlyAskedQuestions
(click on "I understand that Lyrica.....")
 
where I think it really seems to repair the supression of endogenous GABA release to help with sleep, anxiety, and alcohol cravings in that critical post-detox/early recovery period. Even there, I present to the patient as a "trial"--and if it doesn't work, we quit.

I did a pubmed search to see what I could find concerning gabapentin & treating alcoholism.

Unless I missed something, I don't find too much to either condemn or condone it. Several of the studies have small sample sizes, if it did get a good effect, there wasn't replication of the study, and there were a few that didn't show much benefit but suffers the same problems.

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

This above study shows gabapentin to treat insomnia related to alcohol withdrawal. That's the only good study I found and it was only for insomnia vs lorazepam.
 
I did a pubmed search to see what I could find concerning gabapentin & treating alcoholism.

Unless I missed something, I don't find too much to either condemn or condone it. Several of the studies have small sample sizes, if it did get a good effect, there wasn't replication of the study, and there were a few that didn't show much benefit but suffers the same problems.

http://www.ncbi.nlm.nih.gov/sites/e...ez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

This above study shows gabapentin to treat insomnia related to alcohol withdrawal. That's the only good study I found and it was only for insomnia vs lorazepam.

You've piqued my curiosity as well OPD. How do you tend to dose gabapentin when giving for recovering alcoholics? How did you start giving it for alcoholics in the first place? I'm just curious and always eager to learn about new ways of treating things.
 
You've piqued my curiosity as well OPD. How do you tend to dose gabapentin when giving for recovering alcoholics? How did you start giving it for alcoholics in the first place? I'm just curious and always eager to learn about new ways of treating things.

Usually start 300-600 mg qhs. Really anxious, edgy ones I've been known to start at 300 bid + 600 qhs (but I usually reserve this for inpatient, where I can keep an eye on them!):sleep:.

When I was a psych intern in the 90s, GP looked like the perfect wonder drug for everything. (You might have heard there were a few little lawsuits against the manufacturer back then because of a rather cavalier attitude toward labeled indications! :eek:) I soured on it over the next couple of years, but trained with a couple of addiction psychiatrists who at least bothered to do a small study that showed its advantages over trazodone for sleep in alcoholics in early sobreity. My experience has been roughly consistent with theirs.
 
I don't use pregabalin--it's just too expensive, and not prescribed much in our area except for chronic pain conditions, for which it does seem superior to gabapentin. I have patients on it, but they're usually getting it from a pain clinic, not from me.

Had a rep lunch from pfizer this past week where they stated that since lyrica has flat dose pricing, it's the pricing equivalent of brand neurontin at 1600mg daily (according to her). Most managed medicaid plans pay for it as well. I know that I've prescribed a fair amount of it without medicaid payment problems thus far.
 
Anasazi & all,

Just throwing a well written article your way that backed some of your above claims.

Journal of Clinical Psychiatry Nov 2007, vol 68 p 1691
Gabapentin Reduces Alcohol Consumption & Craving: A Randomized, Double Blind, Placebo Controlled Trial
Fernando A. Furieri

I would've put a pubmed link but I don't see it coming up on PubMed. The study used 60 subjects. Results showed significant reduction in number of drinks consumed per day, number of heavy drinking days, & an increase of abstinence, also a decrease in alcohol craving & automaticity of drinking were found in the control vs placebo group.

Control group was given 400-1600 md/day. However the article did report successes with smaller doses.

I'm wondering how this compares with the studies on Campral. I was impressed with the results of the study. I hope more are done with larger sample sizes.
 
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