Lyrica vs Gabapentin: A Family Doctor’s Perspective

After at first being a skeptic I am finding a significant role for Lyrica in treatment of neuropathic pain syndromes.  Lyrica first came to market in December of 2004 in the US with approval for diabetic neuropathic pain and post herpetic neuralgic pain.  I was a slow adopter of this drug. It seemed essentially a high priced alternative to Neurontin, a closely related drug that is used off label for the same indications. It appeared another case of a drug company miraculously coming up with a new and improved version of an old drug shortly before the patent on the old drug expires as I’ve previously discussed with Nexium and Lexapro. (Pfizer markets gabapentin as Neurontin and also pregabalin as Lyrica) Lyrica is pregabalin which is chemically very similar to gabapentin and works by the same mechanism.

Over time I have come to realize that Lyrica does have some distinct advantages over gabapentin. From a practical standpoint the biggest advantage of Lyrica over gabapentin is that I can prescribe a dose of Lyrica that has a chance of working for their painful condition without intolerable Lyrica side effects at the starting dose. The lowest dose of gabapentin that is typically effective for neuropathic pain is 1800 mg daily. Starting a patient at that dose will almost always lead to intolerable drowsiness and an intoxicated sensation of disequilibrium and confusion.  We have to start gabapentin with a slow taper up in dosing to avoid these intolerable side effects. A typical starting regimen would be to start on gabapentin 100 mg three times a day, or 300 mg at bedtime for a few days and then very gradually increase the dose over a couple of weeks or more to a dose of 600 mg three times daily. Most patients do not get adequate pain relief at doses much lower than 1800 mg daily of gabapentin.  Increasing the dose much faster almost guarantees the patient stopping therapy due to these side effects. Using Lyrica I can prescribe 50-75 mg twice daily from the beginning with a good chance that the starting dose will help with the pain. If it takes a higher dose the Lyrica can be increased much faster than gabapentin without causing undue sedation and drugged feeling in most patients.

Other advantages of Lyrica over gabapentin include the faster and more consistent absorption from the gut. About 90% of Lyrica is absorbed from the gut vs. 27-60% of gabapentin being absorbed. In addition the absorption of Lyrica is not dose dependent whereas the higher the dose of gabapentin the lower the absorption rate. Both Lyrica and gabapentin work via a similar mechanism biologically.

For conditions like diabetic peripheral neuropathy I find gabapentin to be a good option. These patients have a chronic condition that has usually been slowly progressive, and gradually beginning a medication with the expectation of help over a few weeks time is acceptable to most of these patients. For more acutely painful conditions like herpes zoster and trigeminal neuralgia the idea of taking up to several weeks for pain relief is much less acceptable. In these conditions Lyrica is far more attractive.

Lyrica was also the first drug with an FDA approval specifically for treating fibromyalgia. Gabapentin is also used off label (without a specific FDA indication for the condition being treated) for fibromyalgia. It is nice as a physician to have a drug with a proven benefit for fibromyalgia as it is a notoriously difficult to treat problem. I have had a couple of patients who have had dramatic improvement of their fibromyalgia on Lyrica and have not had this type of response with gabapentin. I expect that once Lyrica loses its patent and becomes competitive with gabapentin as a generic medication it will nearly replace gabapentin as the drug of choice or treatment of neuropathic pain. For reasons unknown to me gabapentin has not come down dramatically in price like nearly every other generic drug. The cash price of gabapentin 300 mg capsules at Costco is still 14.68/ 100 capsules of the generic product, making the cost of 600 mg three times daily $26.42/ month. This compares favorably though to brand name Neurontin at $391.63 for the same dose or Lyrica 75 mg twice daily of $172.95 / month. My experience has also been that it is difficult to receive authorization from third party payers for Lyrica without previously trying gabapentin, even when gabapentin does not have FDA approval for the condition being treated.

In summary I still use generic gabapentin frequently, and find it a very good drug, but I find that Lyrica sometimes works when gabapentin seems not to be effective and that Lyrica is frequently better tolerated by patients. Especially for patients with fibromyalgia Lyrica is sometimes a remarkably effective drug when not much else seems to work.

66 Responses to Lyrica vs Gabapentin: A Family Doctor’s Perspective

  1. Dr. Pullen says:

    Sandra: according to the Lyrica product information about 2% of persons taking Lyrica will have edema. DrP.

  2. Sandra Lockin says:

    Is Edema common when taking Lyrica?

  3. Dr. Pullen says:

    Kathy: Lots of questions, and I’m not in a position to answer really. It is unusual to be on both Lyrica and gabapentin, but is done occasionally. The weight gain may be related to the meds in part at leasyt. The swelling could be medication related, but needs evaluation for other possible causes unless your physician feels otherwise. You should discuss these concerns with your doctor. GOod Luck. DrP.

  4. kathy says:

    I was diagnosed with osteoarthritis several years ago and fibromyalgia in 1993. I haven’t had too many symptoms over the years until Dec 2012. I worked until my shoulder and arm could not do anything(pizza maker). I had surgery Apr 2013. I have not been able to return to work yet. I am on 2400mg of Gabapentin and 300mg Lyrica as well as 16mg Zanaflex. I recently ran out of my medications (bad, I know) but I found out how much meds really help. Is it safe to take both drugs? My dr just ordered blood work to rule out psoriatic arthritis, rheumatoid and gout. I have not healed well(if at all) after my shoulder surgery. I have terrible muscle spasms that turn into knots under the shoulder blade. I am in physical therapy and have an excellent pain mgmt dr. I don’t have diabetes, but both my parents do. My ankles swell by the end of the day, and I feel almost high when I take the lyrica. It helps the pain I’m in. My weight has gotten out of control. I eat one meal a day and have gained almost 40lbs since I have been out of work.
    Do you have any suggestions for me to bring to my dr? I am at my witts end. I want to go back to work but my body is not cooperating. Is it possible that I can go back to work in the future with the symptoms I am having?

  5. Dr. Pullen says:

    Carole: Lyrica is a consideration especially for the fibromyalgia pain. It is one of only a few medications with an FDA indication for treatment of fibromyalgia pain. It could be used in addition to her current medications if her physician agrees. If it works well she might be able to reduce some other medications. Good luck. DrP.

  6. Carole Cohen says:

    My wife has been suffering from fibromyalgia for many years. In addition she has a bulging of L5. Her pain is in middle back when reaching,and pain at L5 when walking, or playing games like Mah Jong. She is Osteoarthritic ,and is now on. Cymbalta, Elavil, Welbuterin,Ultram, Tylonal,busperone, and Klonopin.
    We anticipate surgical intervention at L5, and she undestands the arthritic pain. However, the arthritic pain and the fibromyalgia pain have become intolerable. She cannot walk any distance. We wonder if Lyrica might help in addition to eliminating some of the other medications.

  7. Dr. Pullen says:

    Lenore: I would not expect as difficult a transition as you portray, but it may be difficult. I think you can work with your physicians to make the switch and see if you can do better. Good Luck. DrP.

  8. Lenore says:

    I was diagnosed with CRPS 2 1/2 years ago. I have been on 3600mg/day of gabapentin for the past 2 years. I have had side effects since the first pill I took but gabapentin does bring my pain down to a 4/10 when combined with nucynta..I am considering changing to Lyrica in hopes I can get rid of the side effects and be able to work once again.My main concern is the transition. My pain doctors said the pain may increase dramatically and it may take months to know if the Lyrica is working. Do you have any other suggestions?

  9. Denise M. Poole says:

    Dr. Pullen,
    Thank you for your quick reply! I am still researching whether to take the Gabapentin, or just try to get off most of my pain meds, which will leave me in so much pain!. I do not want to go through the experence with anything like, or similar to Lyrica again! I am going to ask my Pharmists to research the ingrediences and fillings for each drug There may be a connector. If you can think of other options, please let me know, wish me luck in my research! I would rather corespond by email deniseinbrevard@yahoo.com

  10. Dr. Pullen says:

    Denise: (I removed your last name as it’s not a great idea to put that much specific info on a public blog like this) I agree with your PCP re the taper off the Lyrica. Gabapentin is a reasonable option, though similar side effects are possible. You need to work closely with your physicians to figure out what is best for you. DrP.

  11. Denise P. says:

    Dr. Pullen, I tried Lyria 5+- years ago and after 2 or so months totally went crazy!! I was pariniod, could not go to work for 2 weeks(could have stayed out more), felt every one was looking at me and saying crazy things that I would NEVER say!! I went to the ER (a Professor from the College I worked at took me), they had never experienced anyone with a Lyrica break-down and I do not know that they were familiar with the drug. There was no help from the ER staff-just said to stop with the Med. I got home and called my PCP and told him what had happened, I was still hystrical. He said to NOT stop the MED but to gradually taper off of it, and he gave me a plan that my Husband wrote down. Worst Experience of my life!!!

    Now, my Pain Management Doctor wants me to try Gabapentin,I am too afraid to take it considering my experience with Lyrica.

    Any other suggestions before I go back to the PAIN CLINIC???

    Thank you,
    Denise P.

    What should I do? I know you cannot dignose me on line, but what advise can you give me?

  12. Dr. Pullen says:

    Victoria, re side effects I am not prepared to discuss the comparison in detail. A primary advantage of Lyrica is that most patients can start at a potentially effecive initial dose vs. a slow taper up to dose with gabapentin to avoid excess sedation. See sites like epocrates or http://sideeffectz.com/gabapentinsideeffects for more details.

  13. Dr. Pullen says:

    Victoria: By regulation if a TV ad mentions a drug’s name they have to spend part of the commercial telling about side effects. These always sound terrible and as with all medications there are potential adverse effects. With Lyrica most people tolerate the medication OK, and if they get side effects they are usually reversible by discontinuation of the med. Hopefully you can both find some relief. DrP.

  14. Victoria says:

    Good Morning Doctor.
    This comparison article was very informative, including me understanding why the smaller amt. of GABA I & my mother-in-law have been ‘starting’ hasn’t really helped much at all. So, the tv commmercials make the side effects of LYRICA sound bad. Should we be afraid to ask our doctors to prescrbie them? My mother-in-law has been progressviely becoming more & more miserable over the last few years where the diabetic neuropathic pain is almost intolerable. Sadly, I think I’m on the same road as at 63, more diabetic neuropathic pain is worsening. Thanks in advance for your advise

  15. Dr. Pullen says:

    Dawn: I don’t usually have patients taper off neurontin and onto Lyrica, but simply switch. You should talk with your physician about this, as I cannot give patient specific recommendations here. Halucinations are not common with either med, but might be related to the combination. Again call your doctor. DrP.

  16. Dawn M says:

    Thank you for the information on both meds. Just a question. I was diagnosed with trigememimal neuralgia. My doctor initially prescribed neurotin, which at one point I was taking 900 mg 3x/day, with no relief. Now she has switched me to Lyrica. So currently I am tapering off the neurotin and gradually starting the Lyrica. I am on day 2 of 4 where I am taking 75 mg 1x/day of Lyrica and 900 mg of neurotin 2x/ day. So today, I have been having some hallucinations, which were never an issue before. Could this be a symptom of withdrawing from the Neurotin or a side effect of the Lyrica. It’s a little creepy as this isn’t something I have ever dealt with.

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