THERAPEUTICS

Brands

• Lyrica, Zeegap

Generic?

• No

Class

• Antiepileptic drug (AED)

Commonly Prescribed for

(FDA approved in bold)

• Partial-onset seizures (adjunctive for adults)

• Neuropathic pain associated with post-herpetic neuralgia

• Neuropathic pain associated with diabetic peripheral neuropathy

• Neuropathic pain associated with spinal cord injury

• Fibromyalgia

• Facial pain

• Panic disorder

• Mania or bipolar disorder

• Generalized anxiety disorder

• Alcohol/benzodiazepine withdrawal

How the Drug Works

• Structural analog of GABA that binds at the α2δ subunit of calcium channel (CACNA2D1) and reduces calcium influx. Modulates calcium channel function but not a channel blocker

• Reduces release of excitatory neurotransmitters, such as glutamate, norepinephrine, and substance P

• Inactive at GABA receptors and does not affect GABA uptake or degradation

How Long Until It Works

• Seizures: 2 weeks

• Pain/anxiety: days to weeks

• Fibromyalgia: often in the first week

If It Works

• Seizures: goal is the remission of seizures. Continue as long as effective and well tolerated. Consider tapering and slowly stopping after 2 years without seizures, depending on the type of epilepsy

• Pain: goal is reduction of pain. Usually reduces but does not cure pain and there is recurrence off the medication. Consider tapering for conditions that may improve over time, e.g., post-herpetic neuralgia or fibromyalgia

If It Doesn't Work

• Epilepsy: consider changing to another agent, adding a second agent, using a medical device, or a referral for epilepsy surgery evaluation. When adding a second agent, keep drug interactions in mind

• Pain: if not effective in 2 months, consider stopping or using another agent

Best Augmenting Combos for Partial Response or Treatment-Resistance

• Epilepsy: no major drug interactions with other AEDs. Using in combination may worsen CNS side effects or weight gain

• Neuropathic pain: TCAs, AEDs (gabapentin, pregabalin, carbamazepine, lamotrigine), SNRIs (duloxetine, venlafaxine, milnacipran, mirtazapine, bupropion), capsaicin, and mexiletine are agents used for neuropathic pain. Opioids (morphine, tramadol) may be appropriate for long-term use in some cases but require careful monitoring. Proven to decrease opioid requirements in patients with post-herpetic neuralgia