|Systematic (IUPAC) name|
|Trade names||Lyrica, Nervalin, Gabarol|
|Licence data||US FDA:|
|Biological half-life||6.3 hours|
|CAS Registry Number|
|Molecular mass||159.23 g.mol−1|
|(what is this?)|
Pregabalin, also known as β-isobutyl-γ-aminobutyric acid (β-isobutyl-GABA), is a medication used for epilepsy, neuropathic pain, fibromyalgia, and generalized anxiety disorder. It's use for epilepsy is as an add-on therapy for partial seizures with or without secondary generalization in adults.
Pregabalin is a neurotransmitter modulator. It is also a 3-substituted structural analogue of the endogenous inhibitory neurotransmitter γ-aminobutyric acid (GABA), and a potent gabapentinoid. Pregabalin is also related in structure to gabapentin, as well as of GABOB (β-hydroxy-GABA), baclofen (β-(4-chlorophenyl)-GABA), and phenibut (β-phenyl-GABA). Pfizer developed pregabalin as a successor to gabapentin, and the drug is known to have a more rapid onset of action and be more convenient to use.
Pregabalin is a central nervous system depressant and is considered to have a low potential for abuse and a limited dependence liability if misused. It is classified as a Schedule V controlled substance in the United States.
- 1 Medical uses
- 2 Adverse effects
- 3 Pharmacology
- 4 Pharmacokinetics
- 5 History
- 6 Legal status
- 7 Regulatory status
- 8 See also
- 9 References
- 10 External links
The European Federation of Neurological Societies recommends pregabalin as a first line agent for the treatment of pain associated with diabetic neuropathy, post-herpetic neuralgia, and central neuropathic pain. A minority obtain substantial benefit, and a larger number obtain moderate benefit. Other first line agents, including gabapentin and tricyclic antidepressants, are given equal weight as first line agents, and unlike pregabalin, are available as inexpensive generics.
Pregabalin is not recommended for certain other types of neuropathic pain such as pain that of trigeminal neuralgia or HIV infection and its use in cancer-associated neuropathic pain is controversial. There is no evidence for its use in the prevention of migraines and gabapentin has been found not to be useful. It has been examined for the prevention of post-surgical chronic pain, but its utility for this purpose is controversial.
Pregabalin is generally not regarded as efficacious in the treatment of acute pain. In clinical trials examining the utility of pregabalin for the treatment of acute post-surgical pain, no effect on overall pain levels was observed, but people did required less morphine and had fewer opioid-related side effects.
It has also been found effective for generalized anxiety disorder and is (as of 2007) approved for this use in the European Union and Russia. The World Federation of Biological Psychiatry recommends pregabalin as one of several first line agents for the treatment of generalized anxiety disorder, but recommends other agents such as SSRIs as first line treatment for obsessive-compulsive disorder and post-traumatic stress disorder. It appears to have anxiolytic effects similar to benzodiazepines with less risk of dependence.
Therapeutic effects of pregabalin appear after 1 week of use and is similar in effectiveness to lorazepam, alprazolam, and venlafaxine, but pregabalin has demonstrated superiority by producing more consistent therapeutic effects for psychic and somatic anxiety symptoms. Long-term trials have shown continued effectiveness without the development of tolerance, and, in addition, unlike benzodiazepines, it has a beneficial effect on sleep and sleep architecture, characterized by the enhancement of slow-wave sleep. and produces less severe cognitive and psychomotor impairment; it also has a low potential for abuse and dependence and may be preferred over the benzodiazepines for these reasons.
Pregabalin has been shown to produce therapeutic effects that are similar to other controlled substances. In a study with recreational users of sedative and hypnotic drugs, a 450 mg dose of pregabalin resulted in subjective ratings of a "good drug effect" and "high" and "liking" similar to 30 mg of diazepam. In clinical studies, pregabalin showed an adverse drug reaction profile similar to other central nervous system depressants.
- Very common (>10% of patients): dizziness, drowsiness.
- Common (1–10% of patients): blurred vision, diplopia, increased appetite and subsequent weight gain, euphoria, confusion, vivid dreams, changes in libido (increase or decrease), irritability, ataxia, attention changes, abnormal coordination, memory impairment, tremors, dysarthria, parasthesia, vertigo, dry mouth and constipation, vomiting and flatulence, erectile dysfunction, fatigue, peripheral edema, drunkenness, abnormal walking, asthenia, nasopharyngitis, increased creatine kinase level.
- Infrequent (0.1–1% of patients): depression, lethargy, agitation, anorgasmia, hallucinations, myoclonus, hypoaesthesia, hyperaesthesia, tachycardia, excessive salivation, hypoglycaemia, sweating, flushing, rash, muscle cramp, myalgia, arthralgia, urinary incontinence, dysuria, thrombocytopenia, kidney calculus
- Rare (<0.1% of patients): neutropenia, first degree heart block, hypotension, hypertension, pancreatitis, dysphagia, oliguria, rhabdomyolysis, suicidal thoughts or behavior.
Several renal failure patients developed myoclonus while receiving pregabalin, apparently as a result of gradual accumulation of the drug. Acute overdosage may be manifested by somnolence, tachycardia and hypertonicity. Plasma, serum or blood concentrations of pregabalin may be measured to monitor therapy or to confirm a diagnosis of poisoning in hospitalized patients.
Following abrupt or rapid discontinuation of pregabalin, some people reported symptoms suggestive of physical dependence. The FDA determined that the substance dependence profile of pregabalin, as measured by a patient physical withdrawal checklist, was quantitatively less than benzodiazepines. Even people who have discontinued short term and or long term use of pregabalin have experienced withdrawal symptoms, including insomnia, headache, nausea, anxiety, diarrhea, flu like symptoms, nervousness, major depression, pain, convulsions, hyperhidrosis and dizziness.
Pregabalin binds to the α2δ subunit of voltage-gated calcium channels in the central nervous system. Although, pregabalin is a 3-substituted structural analogue of the endogenous inhibitory neurotransmitter γ-aminobutyric acid (GABA), it does not bind directly to GABAA, GABAB, or benzodiazepine receptors. Gabapentinoids, such as pregabalin, are α2δ subunit voltage-gated calcium channel modifiers that affect GABA. In contrast to the distribution of α2δ-1 and α2δ-2 subunits binding correlates partially with GABAergic neurons. Pregabalin increases the density of GABA transporter proteins and increases the rate of functional GABA transport. Pregabalin does not block sodium channels and is not active at opioid receptors. It is inactive at serotonin receptors and dopamine receptors and does not inhibit dopamine, serotonin, or noradrenaline reuptake.
Both α2δ subunit binding sites are also known for three other different gabapentinoids. That being gabapentin, gabapentin enacarbil, and phenibut. Recently, phenibut (β-phenyl-GABA), a close analogue of pregabalin (β-isobutyl-GABA), has been found to similarly bind to the α2δ subunit of voltage-gated calcium channels and phenibut inhibits these channels similarly to gabapentin and pregabalin. Baclofen (β-(4-chlorophenyl)-GABA) has also been found to do this, but relatively weakly. Moreover, it has been found that the antinociceptive effects of phenibut in rodents are mediated not by GABAB receptor but by blockade of α2δ subunit-containing voltage-gated calcium channels, implicating this action as an important mediator of the effects of phenibut. Phenibut has the same structure of baclofen (lacking only a chlorine atom in the para-position of the phenyl group) and includes the phenylethylamine structure. Pregabalin has instead the phenyl group substituted with the isobutyl group. Making both phenibut and baclofen close analogues of pregabalin. 
The biological half-life for pregabalin is 6.3 hours.
Pregabalin is rapidly absorbed when administered on an empty stomach, with peak plasma concentrations occurring within one hour. Pregabalin oral bioavailability is estimated to be greater than or equal to 90% and is independent of dose. The rate of pregabalin absorption is decreased when given with food resulting in a decrease in Cmax by approximately 25 to 30% and a delay in Tmax (time to reach Cmax) to approximately 2.5 hours. Administration with food, however, has no clinically significant effect on the extent of absorption.
Pregabalin has been shown to cross the blood–brain barrier in mice, rats, and monkeys. Pregabalin has been shown to cross the placenta in rats and is present in the milk of lactating rats. In humans, the volume of distribution of pregabalin for an orally administered dose is approximately 0.56 L/kg and is not bound to plasma proteins.
Pregabalin undergoes negligible metabolism in humans. In experiments using nuclear medicine techniques, it was revealed that approximately 98% of the radioactivity recovered in the urine was unchanged pregabalin. The major metabolite is N-methylpregabalin.
Pregabalin was discovered by medicinal chemist Richard Bruce Silverman at Northwestern University in the United States. The drug was approved in the European Union in 2004. Pregabalin received U.S. FDA approval for use in treating epilepsy, diabetic neuropathic pain, and postherpetic neuralgia in December 2004, and appeared on the U.S. market in fall 2005.
In June 2007, the FDA approved Lyrica as a treatment for fibromyalgia. It was the first drug to be approved for this indication and remained the only one until duloxetine gained FDA approval for the treatment of fibromyalgia in June 2008.
- US: Pregabalin is a Schedule V controlled substance and is classified as a central nervous system depressant. The potential for abuse of pregabalin is less than the potential with benzodiazepines.
- Norway: Pregabalin is in prescription Schedule C, the lowest schedule, although it has been suggested that it be moved to Schedule B alongside benzodiazepines.
- Russia: Due to widespread non-prescription misuse (especially by opiate abusers), pregabalin is Schedule III controlled substance, in the same list as all benzodiazepines (except phenazepam) and barbiturates.
In the United States, the Food and Drug Administration (FDA) has approved pregabalin for adjunctive therapy for adults with partial onset seizures, management of postherpetic neuralgia and neuropathic pain associated with spinal cord injury and diabetic peripheral neuropathy, and the treatment of fibromyalgia. Pregabalin has also been approved in the European Union and Russia (but not in US) for treatment of generalized anxiety disorder.
Pregabalin is marketed by Pfizer under the trade name Lyrica. Pfizer described in an SEC filing that the drug could be used to treat epilepsy, postherpetic neuralgia, diabetic peripheral neuropathy and fibromyalgia. Lyrica was promoted for other uses which had not been approved by medical regulators up until 2009. For this practice, with three other drugs, Pfizer was fined a record amount of US$2.3 billion by the Department of Justice. Lyrica sales reached a record US$3.063 billion in 2010. Lyrica is one of four drugs which Pharmacia & Upjohn, a subsidiary of Pfizer, in 2009 pleaded guilty to misbranding "with the intent to defraud or mislead". Pfizer agreed to pay US$2.3 billion (GB£1.4 billion) in settlement, and entered a corporate integrity agreement. Pfizer illegally promoted the drugs and caused false claims to be submitted to government healthcare programs for uses that were not approved by the U.S. Food and Drug Administration (FDA).
Northwestern University invented pregabalin and holds a patent on it, which it exclusively licensed to Pfizer. That patent, along with others, was challenged by generic manufacturers and was upheld in 2014, giving Pfizer exclusivity for Lyrica in the US until 2018.
Other available forms
- GABA analogue
- Gabapentin (Neurontin)
- Gabapentin enacarbil (Horizant)
- Baclofen (Gablofen, Lioresal)
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