Pregabalin is an anticonvulsant used to relieve neuropathic pain and is used with other medications to treat certain types of seizures. It works by decreasing the number of pain signals that are sent out by damaged nerves in the body. Pregabalin comes as a capsule to take by mouth. Pregabalin has been studied in patients with cancer as an intervention for pain and peripheral neuropathy. It has also been studied for its effect on anxiety and sleep-wake disturbances.
The U.S. Food and Drug Administration (FDA) has issued a warning regarding the use of gabapentin or pregabalin and serious breathing difficulties in people with respiratory risk factors, including older adults, those having conditions that reduce lung function such as chronic obstructive pulmonary disease (COPD), and those using drugs that depress the central nervous system including opioids, anti-anxiety medication, antidepressants, and antihistamines.
de Andrade, D.C., Jacobsen Teixeira, M., Galhardoni, R., Ferreira, K.S.L., Braz Mileno, P., Scisci, N., . . . de Souza, A.M. (2017). Pregabalin for the prevention of oxaliplatin-induced painful neuropathy: A randomized, double-blind trial. Oncologist, 22, 1154–1155, e99–e105.
Evaluate the effect on pregabalin given three days prior and three days after each oxaliplatin dose on oxaliplatin-induced peripheral neuropathy
Pregabalin versus placebo given three days prior to and three days after oxaliplatin infusion on weeks 1, 3, and 5 of an 8-week cycle.
PHASE OF CARE: Active anti-tumor treatment
Randomized, placebo controlled trial
Main outcome was pain level based on the visual analog scale (rating 0-10) and the brief pain inventory (BPI). Secondary endpoints were the presence of pain from neuropathy as well the severity of pain based on the Douleur Neuropathique–4 (DN-4), the short-form McGill Pain Questionnaire (MPQ), the Neuropathic Pain Symptom Inventory (NPSI), and any changes in the nerve conduction studies as well as subjective side effect profile.
The pain intensity level of the pregabalin group was 1.03 (95% CI [0.76, 1.26]) and was 0.85 in the placebo group (95% CI [0.64, 1.06]). Quality-of-life scores did not differ between the two groups (placebo QOL was 76.9 [SD = 23.1] and the pregabalin QOL was 79.4 [SD = 20.6]). There were no significant differences in any of the outcome measures.
The intervention was safe, but did not decrease the pain severity or incidence of oxaliplatin-induced peripheral neuropathy.
Pregabalin may be safe to take, but does not prevent neuropathy in those receiving oxaliplatin.
Mishra, S., Bhatnagar, S., Goyal, G.N., Rana, S.P., & Upadhya, S.P. (2012). A comparative efficacy of amitriptyline, gabapentin, and pregabalin in neuropathic cancer pain: A prospective randomized double-blind placebo-controlled study. American Journal of Hospice and Palliative Care, 29, 177–182.
To compare the efficacy of amitryptylline, gabapentin, and pregabalin in patients with cancer experiencing neuropathic pain
Patients were randomly assigned to amitryptyllin (AT), gabapentin (GB), pregabalin (PG), or placebo. AT was given at 50 mg/day for one week, then increased incrementally to 100 mg/day. GB was given at 900 mg/day for one week in divided doses, then increased to 1,800 mg/day by week 3. PG was given at 150 mg/day for one week, then increased to 600 mg/day by week 3. The control group received placebo capsules. Morphine was used as rescue pain medication as needed. Patients were evaluated weekly for four weeks.
The study has clinical applicability for late effects and survivorship.
The study was a placebo-controlled, randomized trial.
VAS scores decreased in all groups. In week 4, those on pregabalin had significantly lower VAS scores than other groups, and scores declined by 4–5 points (p < 0.03). By the third visit, the percentage of patients who required morphine rescue increased: 46.7% with AT, 23.3% with GB, 16.7% with PG, and 100% with placebo. Lancinating pain incidence was lowest in the PG group. There were significantly fewer patients with dysesthesia in the PG group (6.7%) compared to the GB and placebo groups after four weeks. The percentage of patients with allodynia declined in all groups. The PG group showed a statistically significant improvement in ECOG score compared to all other groups (p < 0.001). Satisfaction was similar in all groups, and there were no significant differences in adverse reactions, with a gradual increase in all groups over time. Adverse effects were somnolence, dizziness, nausea, constipation, and dry mouth.
All of the drugs tested here demonstrated some efficacy in improving neuropathic symptoms. In several areas, it appears that pregabalin was more effective than gabapentin, opioid monotherapy, and amitryptylline. All medications were given in combination with opioids for pain management.
All of the medications examined in this study were effective and had a morphine-sparing effect in the treatment of neuropathic pain and other symptoms. Pregabalin was more effective than other alternatives tested in some areas. As all patients in this study received opioids for pain rescue, it should be noted that essentially all medications compared were given in combination with opioids.
Saif, M.W., Syrigos, K., Kaley, K., & Isufi, I. (2010). Role of pregabalin in treatment of oxaliplatin-induced sensory neuropathy. Anticancer Research, 30, 2927–2933.
The study goal was to assess the efficacy of pregabalin in the treatment of oxaliplatin-induced neurotoxicity.
Patients receiving oxaliplatin with grade 2 and 3 sensory neuropathy were treated with pregabalin up to a target dose of 150 mg orally three times a day. Neurologic symptoms were serially evaluated before treatment initiation with pregabalin and every two weeks thereafter, recording intensity and duration of the symptom. Interference with activities of daily living (ADLs) were evaluated. Patients started pregabalin at 50 mg three times per day. If tolerated, the dose was increased by 50 mg increments until symptoms improved to a max of 150 mg three times per day.
The study was conducted at an outpatient university setting in the United States.
The study had a prospective trial design.
National Cancer Institute common toxicity criteria
Five of the 23 participants were escalated to 150 mg of pregabalin with benefit and tolerance. Seven of the 23 escalated to 100 mg with benefit and tolerance. Four stopped due to no benefit, five could not be increased above 50 mg three times daily, two continued at this dose, and three stopped because of CNS side effects. Onset of benefit observed in 2–6 weeks. Three patients' neuropathy improved from grade 3 to grade 2, two patients improved from grade 3 to grade 1, and six patients improved from grade 2 to grade 1. No patients remained at grade 3 and five remained stable at grade 2. The five most common toxicities of pregabalin were dizziness, headache, somnolence, dry mouth, ataxia, and tremor.
Pregabalin at a dose of 100 mg–150 mg three times daily appears to decrease sensory neuropathy in some patients receiving oxaliplatin. Pregabalin was associated with side effects that limited the ability to tolerate the medication or dose escalation.
Pregabalin may be another alternative in treating chemotherapy-induced neuropathy for some patients. Findings suggest that pregabalin is not effective for everyone. In addition, the drug is expensive and is a controlled substance, which can limit the use. Pregabalin has side effects that need to be considered, including CNS side effects that required drug discontinuation. Patients receiving this agent need to be monitored appropriately for both effectiveness and potential side effects.
Shinde, S.S., Seisler, D., Soori, G., Atherton, P.J., Pachman, D.R., Lafky, J., . . . Loprinzi, C.L. (2016). Can pregabalin prevent paclitaxel-associated neuropathy? An ACCRU pilot trial. Supportive Care in Cancer, 24, 547–553.
To investigate the potential role of pregabalin in the prevention of chemotherapy-induced neuropathy
Patients were randomized to receive placebo or pregabalin 75 mg twice daily starting on the first night of chemotherapy and throughout 12 weeks of chemotherapy. In week 13, the dose was reduced to once daily at bedtime. Patients were instructed to use acetaminophen or oxycodone as needed for breakthrough pain. For the first six days, pain severity and analgesic use were obtained daily; on day 8, they were obtained prior to each subsequent paclitaxel treatment; and they were obtained for six months 30 days after the completion of paclitaxel treatment.
PHASE OF CARE: Active antitumor treatment
Double-blind, placebo-controlled trial
No differences existed between groups in worst, average, or least pain scores, or in analgesic use. No differences existed in the motor neuropathy or autonomic neuropathy subscale scores of the EORTC instrument. No significant differences were observed in adverse events.
The findings did not support any effect of pregabalin for the prevention of chemotherapy-induced neuropathic symptoms.
Professional guidelines have suggested that gabapentinoids may be considered as an option to treat chemotherapy-induced neuropathy, although their effectiveness has not been established. This study provides limited evidence to suggest that pregabalin, a type of gabapentinoid, is effective for the prevention or reduction of paclitaxel-induced neuropathic symptoms. Given these results, it may not effectively treat established neuropathic symptoms. Currently, limited treatment options exist for the prevention or management of chemotherapy-induced peripheral neuropathy. Nurses need to be aware of chemotherapy agents that have neurotoxic effects, and monitor patients for early detection of such effects to identify the need for potential treatment dose modification.
Toth, C. (2010). Substitution of gabapentin therapy with pregabalin therapy in neuropathic pain due to peripheral neuropathy. Pain Medicine, 11, 456–465.
The goal of the study was to determine utility of substitution of pregabalin for gabapentin therapy in relief of neuropathic pain.
All patients starting on gabapentin and all patients already using gabapentin as monotherapy were offered the choice of replacing their gabapentin with pregabalin. Comparison was made between the groups switched to pregabalin and a cohort group of patients with peripheral neuropathy and pain receiving only gabapentin without a switch to pregabalin.
The study was conducted at a single site in Canada.
Cohort study
Both gabapentin responder and nonresponders groups had additional pain relief of about 25% following substitution of pregabalin after 6 and 12 months. The percentage of improvement on the EQ-5D VAS was significant (p < 0.025).
Findings show that pregabalin may provide pain relief in this patient population.
The findings support that notion that both pregabalin and gabapentin may provide pain relief in some patients with peripheral neuropathy. The majority of cases were patients with diabetes. Application to patients with cancer is unclear.
Vondracek, P., Oslejskova, H., Kepak, T., Mazanek, P., Sterba, J., Rysava, M., & Gal, P. (2009). Efficacy of pregabalin in neuropathic pain in paediatric oncological patients. European Journal of Paediatric Neurology, 13, 332–336.
The aim of the study was to evaluate the safety and efficacy of pregabalin in the management of chemotherapy-induced neuropathic pain.
Children were medicated with pregabalin twice daily starting at 75 mg per day and titrated upwards by 75 mg daily with doses ranging from 150–300 mg for eight weeks. No patient was receiving chemotherapy at the time of pregabalin administration. Patients were evaluated prior to treatment and at weeks 2, 4, 6, and 8 of treatment using a visual analog scale. Patients were asked about side effects.
The study was conducted at a single outpatient setting in the Czech Republic.
The study had a prospective trial design.
Visual analog scale
The mean visual analog scale score decreased by 59% from baseline during eight weeks of pregabalin with statistically significant improvement in pain symptoms (p < 0.001). A marked pain relief was noted in 14, moderate pain relief in 10, mild pain relief in two, and no pain relief in two patients. Adverse effects were mild or moderate.
Pregabalin appears to be safe and effective in treating pediatric patients with cancer suffering from chemotherapy-induced peripheral neuropathy. Pregabalin has mild to moderate adverse effects.
Pregabalin has been shown to be effective in relieving pain from chemotherapy in pediatric patients; however, pregabalin is expensive and a controlled drug. Preagabalin has mild to moderate side effects and was tolerated without major complications.