Pregabalin


  Issues for Surgery


For treatment of epilepsy – precipitation of rebound seizures or status epilepticus if omitted.

For peripheral neuropathic pain – loss of pain management if omitted.

For treatment of generalised anxiety disorder – risk of anxiety disorder returning if omitted.

Risk of withdrawal symptoms (insomnia, headache, nausea, anxiety, diarrhoea, depression, pain) if omitted1.

 

  Advice in the Perioperative period


Elective and Emergency Surgery

Continue.

Epilepsy
Patients should be advised to take their regular medications on the day of surgery2, 3, 4.

Abrupt withdrawal of any anticonvulsant drug should be avoided1.

Confirm with the patient if they need to be maintained on a specific manufacturer’s product (see Further Information).

Other Indications
Product information states that care is required when withdrawing pregablin therapy, regardless of the indication5.

Post-operative Advice

Regular dosing of the patient’s usual oral medication should be re-established as early as possible post-operatively3, 4.

Pregabalin is only available as oral preparations. For epilepsy patients, if they cannot resume their usual oral medication post-operatively, the advice of a Neurologist should be sought to determine the most appropriate antiepileptic preparation, dose, route and frequency to be used. For other indications, monitor the patient for signs of withdrawal symptoms. Consider alternative treatment options as appropriate and seek the advice of a specialist where necessary.


  Interaction(s) with Common Anaesthetic Agents


For general information regarding the use of anaesthetic agents in patients with epilepsy – see Antiepileptics – A General Overview.

Central Nervous System (CNS) Depression

In post-marketing experience, there are reports of respiratory failure and coma in patients taking pregabalin and other CNS depressant medicinal products1, especially with opioids2 – see Further Information.

Remifentanil

Pregabalin enhanced the analgesic effects of remifentanil in one study6.


  Interaction(s) with other Common Medicines used in the Perioperative Period


For general information regarding the use of antiemetics in patients with epilepsy – see Antiepileptics – A General Overview.

Opioids (see also Interaction(s) with Common Anaesthetics Agents and Further Information)

The manufacturers state that there is no clinically relevant pharmacokinetic interaction between oxycodone and pregabalin6. However, concurrent use appeared to cause an additive impairment in cognitive and gross motor function1, 6. The degree of impairment will depend on the individual patient6.

Gastrointestinal Tract Function

There are post-marketing reports of events related to reduced lower gastrointestinal tract function (e.g. intestinal obstruction, paralytic ileus, constipation) when pregabalin was co-administered with medications that have the potential to produce constipation, such as opioid analgesics. When pregabalin and opioids will be used in combination, measures to prevent constipation should be considered (especially in female or elderly patients)1.


  Further Information


MHRA/CHM Advice: Antiepileptic Drugs: updated advice on switching between different manufacturer’s products (November 2017)2

Pregabalin is a category 3 antiepileptic, hence it is usually unnecessary to ensure that patients are maintained on a specific manufacturer’s product unless there are specific concerns such as patient anxiety, and risk of confusion or dosing errors. (For more information see Antiepileptics – A General Overview).

MHRA/CHM advice: Pregabalin (Lyrica®) and risk of abuse and dependence: new scheduling requirements from 1 April (April 2019)2

Patients should be informed of the potentially fatal risks of interactions between pregabalin and other medicines that can cause CNS depression, particularly opioids.


  References


  1. Summary of Product Characteristics – Lyrica® (pregabalin) 300mg hard capsules. Pfizer Limited. Accessed via www.medicines.org.uk 20/07/2019 [date of revision of the text May 2019]
  2. Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press http://www.medicinescomplete.com [Accessed on 15th July 2019]
  3. Perks A, Cheema S, Mohanraj R. Anaesthesia and epilepsy. BJA: British Journal of Anaesthesia. 2012; 108(4):562-571
  4. Carter EL, Adapa RM. Adult epilepsy and anaesthesia. BJA Education. 2015; 15(3):111-117
  5. Pregabalin. In: Brayfield A (Ed), Martindale: The Complete Drug Reference. London: The Royal Pharmaceutical Society of Great Britain. http://www.medicinescomplete.com [Accessed 20th July 2019]
  6. Baxter K, Preston CL (eds), Stockley’s Drug Interactions (online) London: Pharmaceutical Press. http://www.medicinescomplete.com [Accessed on 20th July 2019]