Practice Review – Revisiting pregabalin: Optimising safety in prescribing for neuropathic pain

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Further aggregate data (national and by remoteness area) are provided below to complement your individual Practice Review. Where data vary between RAs, data for all five RAs are presented alongside national-level data.

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Points for reflection

• For chronic neuropathic pain consider a TCA (amitriptyline or nortriptyline) or an SNRI (duloxetine or venlafaxine) or a gabapentinoid (pregabalin or gabapentin). Base choice on individual patient factors and medicine properties.¹⁵
• Advise patients of common adverse effects,²² and risk of dependency and misuse with pregabalin.^5,23 Gabapentinoids (particularly pregabalin), TCAs and SNRIs can worsen mood and cause suicidal thoughts. Assess individual patient risk before prescribing.¹⁵
• For acute neuropathic pain, gabapentinoids may be preferred due to their faster onset of action, but their use may be limited by potential harms. Consider a TCA or SNRI if a gabapentinoid is not appropriate.¹⁵
• Lidocaine 5% patches are preferred options for patients with localised neuropathic pain, particularly for older or frail patients and those on multiple medicines.¹⁵
• Gabapentin, nortriptyline, duloxetine, venlafaxine and lidocaine are not available on the PBS for neuropathic pain.

This graph shows the number of unique patients (nationally) dispensed a prescription for pregabalin and/or amitriptyline expressed as a rate per 1000 unique patients who had a Medicare category 1 consultation in that financial year.

See these data broken down by remoteness area (RA)

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Points for reflection

• Take a targeted history and perform a physical examination (including sensory testing) to help determine a probable diagnosis before starting a medicine.¹⁹ Consider using a validated screening tool, eg DN4²⁰ or painDETECT.^15,21
• Do not use imaging solely to confirm diagnosis – reserve it for cases where findings will change management.¹⁵
• Do not use pregabalin as a diagnostic tool for neuropathic pain. Approximately eight patients with neuropathic pain need to be treated with pregabalin for one to achieve a 50% reduction in pain not attributable to placebo.¹⁵

Note: Based on twice-daily dosing, each pack of pregabalin should usually last 28 days.

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Points for reflection

• Start with a low dose, increasing slowly to minimise adverse effects.  Benefits should be apparent after around 4 weeks. Continue if effective, and tolerated – if not, consider tapering, then trialling an alternative.¹⁵
• Trial deprescribing every 3–6 months to assess ongoing benefits and reduce risk of adverse effects.¹⁵

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Points for reflection

• Exercise caution when prescribing pregabalin² particularly for patients at increased risk of misuse⁶ eg, those with multiple prescribers.²
• Continue to monitor for signs of tolerance, misuse and/or abuse, such as increase in dose or drug-seeking behaviour.^8,24 The introduction of Real Time Prescription Monitoring (RTPM) may help highlight potential medicine misuse.

Note: Medicines may not have been prescribed at the same time. Prescriptions for injectable medicines, as well as those indicated solely for cancer pain, palliative care or dependence, are not included. Due to rounding, percentages do not equal 100%.

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Points for reflection

• Ask patients what other medicines they are using before you prescribe pregabalin. Explain the significant risks of using pregabalin with medicines such as opioids and benzodiazepines, and with illicit drugs. Tell them to inform any other health professionals they see that they are taking pregabalin.
• Avoid co-prescribing pregabalin with central nervous system depressants if possible.²² Most fatal overdoses involving pregabalin also involve other drugs, predominantly opioids,^2,4 benzodiazepines,^2,4 alcohol,^2,4 illicit drugs² and antidepressants.⁴

Find additional resources to support diagnosing neuropathic pain

• demonstration videos of sensory tests
• a patient action plan 
• information on pregabalin misuse.

Find information for your patients