Pregabalin

Effects

AnxiolyticSedativeMuscle RelaxantAmnesiaDystaxiaHypnotic TS

Overview

Pregabalin (also known as 3-isobutyl GABA and by the trade-name Lyrica) is a depressant substance of the gabapentinoid class. Pregabalin is a common prescription drug, which is typically used to treat neuropathic pain, anxiety, restless leg syndrome, and as an adjunct drug in the treatment of seizures.[1][2] PW

Pregabalin (Lyrica) is a GABA derivative that is used to treat neuropathic pain and seizures, as well as anxiety.[3] TS

Pregabalin, sold under the brand name Lyrica among others, is an anticonvulsant, analgesic, and anxiolytic amino acid medication used to treat epilepsy, neuropathic pain, fibromyalgia, restless legs syndrome, opioid withdrawal, generalized anxiety disorder (GAD), and postherpetic neuralgia (a type of nerve damage that can result from shingles). Pregabalin also has antiallodynic properties. Its use in epilepsy is as an add-on therapy for partial seizures. When used before surgery, it reduces pain but results in greater sedation and visual disturbances. It is taken by mouth.[4–11] WP

Common side effects can include headache, dizziness, sleepiness, euphoria, confusion, trouble with memory, poor coordination, dry mouth, problems with vision, and weight gain. Serious side effects may include angioedema, kidney damage, and seizures.[4][12][13] WP

As with all other drugs approved by the FDA for treating epilepsy, the pregabalin labeling warns of an increased suicide risk when combined with other drugs. When pregabalin is taken at high doses over a long period of time, addiction may occur, but if taken at usual doses the risk is low. Use during pregnancy or breastfeeding is of unclear safety.[4][14][15][16] WP

It is a gabapentinoid medication, a class of drugs within the chemical derivatives of γ-aminobutyric acid (GABA analogues), an inhibitory neurotransmitter. Although pregabalin is inactive at GABA receptors and GABA synapses, it acts by binding specifically to the α₂δ-1 protein that was first described as an auxiliary subunit of Voltage-gated calcium channels.[4][8][17–20] WP

Pregabalin was approved for medical use in the United States in 2004. In the US, pregabalin is a Schedule V controlled substance under the Controlled Substances Act of 1970, which means it has low abuse potential compared to substances in Schedules I–IV, though there is still a potential for misuse. It is available as a generic medication. In 2023, it was the 78th most commonly prescribed medication in the United States, with more than 8 million prescriptions.[4][12][21–27] WP

History

History

Pregabalin was synthesized in 1990 as an anticonvulsant that was developed as a successor to the related gabapentin. It was first synthesized by medicinal chemist Richard Bruce Silverman at Northwestern University in Evanston, Illinois. During 1988 to 1990, Ryszard Andruszkiewicz, a visiting research fellow, synthesized a series of molecules requested by Silverman. Upon testing in mouse seizure models by collaborators at Parke-Davis Pharmaceuticals, one looked particularly promising. In vitro, it activated L-glutamic acid decarboxylase, an enzyme, but this later proved to be unimportant to prevention of seizures. Silverman had originally hoped that the enzyme would increase the production of the inhibitory neurotransmitter GABA and block convulsions. After extensive development studies and clinical trials by Parke-Davis the drug was approved in the European Union in 2004. The US received FDA approval for use in treating epilepsy, diabetic neuropathic pain, and postherpetic neuralgia in December 2004. Pregabalin then appeared on the US market under the brand name Lyrica in the fall of 2005. In 2017, the FDA approved pregabalin extended-release Lyrica CR for the management of neuropathic pain associated with diabetic peripheral neuropathy, and postherpetic neuralgia. However, unlike the immediate release formulation, Lyrica CR was not approved for the management of fibromyalgia or as add-on therapy for adults with partial onset seizures.[41–49] WP

Legal status

• Pregabalin is regulated as a prescription drug in most countries. PW
• Germany: Pregabalin is a prescription medicine, according to Anlage 1 AMVV.[50] PW
• Norway: Pregabalin is in prescription schedule B alongside most benzodiazepines and painkillers. It was rescheduled to schedule B from the less restrictive schedule C because of reported recreational use, tolerance development and addiction.[51] PW
• Sweden: Pregabalin is a prescription drug. classified as a controlled substance, as a schedule V drug, since 24 july 2018[52] PW
• Switzerland: Pregabalin is listed as a "Abgabekategorie B" pharmaceutical, which requires a prescription. PW⚠ PsychonautWiki itself has flagged this text: citation needed.
• Turkey: Pregabalin is a 'green prescription' only substance and illegal when sold or possessed without a prescription.[53] PW⚠ PsychonautWiki itself has flagged this text: citation needed.
• United Kingdom: The Misuse of Drugs Act 1971 makes it illegal to possess the drug without a prescription and, for such purposes, it is classified as a Class C drug.[54] PW
• United States: Pregabalin is in Schedule V, indicating "low potential for abuse." For comparison, benzodiazepines are in Schedule IV.[55] PW

Legal status

• United States: During clinical trials a small number of users (~4%) reported euphoria after use, which led to its control in the US. The Drug Enforcement Administration (DEA) classified pregabalin as a depressant and placed pregabalin, including its salts, and all products containing pregabalin into Schedule V of the Controlled Substances Act.[56–59] WP
• Norway: Pregabalin is in prescription Schedule B, alongside benzodiazepines.[60][61] WP
• United Kingdom: On January 14, 2016, the Advisory Council on the Misuse of Drugs (ACMD) recommended that pregabalin, along with gabapentin, be controlled under the Misuse of Drugs Act 1971. In October 2018, it was announced that pregabalin would be reclassified as a Class C controlled substance, effective April 2019. As a Class C drug, pregabalin now requires a prescription in the UK, and the prescription must clearly specify the dose.[62–68] WP
• Australia: Pregabalin has been classified as Schedule 4 (prescription only) since its registration in Australia in 2005. Despite this classification, concerns about misuse and deaths led the Therapeutic Goods Administration (TGA) to add boxed warnings regarding abuse and dependence to pregabalin's prescribing information in 2021. Data from the National Coronial Information System showed pregabalin-related deaths rose from 16 in 2013 to 121 in 2016, and a 2019 study in the Medical Journal of Australia found over a tenfold increase in pregabalin-related ambulance attendances in Victoria between 2012 and 2017. Pregabalin is subject to real-time prescription monitoring in all states and territories.[69–73] WP

In the United States, the 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. In Australia, the TGA has approved pregabalin for neuropathic pain in adults and epilepsy, it is not approved in Australia for generalized anxiety disorder or fibromyalgia. Pregabalin has also been approved in the European Union, the United Kingdom, and Russia for treatment of generalized anxiety disorder.[74–78] WP

Economics

Pregabalin is available as a generic medication in a number of countries, including the United States as of July 2019. In the United States as of July 2019 the wholesale/pharmacy cost for generic pregabalin is $0.17–0.22 per 150-mg capsule.[12][22][76][79] WP

From 2008 until 2018, Pfizer engaged in extensive direct-to-consumer advertising campaigns to promote its branded product Lyrica for fibromyalgia and diabetic nerve pain indications. In January 2016, the company spent a record amount, $24.6 million for a single drug on TV ads, reaching global revenues of $14 billion, more than half in the United States.[80] WP

Up until 2009, Pfizer promoted Lyrica for other uses that had not been approved by medical regulators. For Lyrica and three other drugs, Pfizer was fined a record amount of $2.3 billion by the Department of Justice, after pleading guilty to advertising and branding "with the intent to defraud or mislead". Pfizer illegally promoted the drugs, with doctors "invited to consultant meetings, many in resort locations; attendees expenses were paid; they received a fee just for being there", according to prosecutor Michael Loucks.[81][82][83] WP

Intellectual property

Northwestern University in the US holds the patent on pregabalin, 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.[84–87] WP

Pfizer's main patent for Lyrica, for seizure disorders, in the UK expired in 2013. In November 2018, the Supreme Court of the United Kingdom ruled that Pfizer's second patent on the drug, for the treatment of pain, was invalid because there was a lack of evidence for the conditions it covered—central and peripheral neuropathic pain. From October 2015, GPs were forced to change people from generic pregabalin to branded until the second patent ran out in July 2017. This cost the NHS £502 million.[88] WP

Brand names

As of October 2017, pregabalin is marketed under many brand names: Algerika, Alivax, Alyse, Alzain, Andogablin, Aprion, Averopreg, Axual, Balifibro, Brieka, Clasica, Convugabalin, Dapapalin, Dismedox, Dolgenal, Dolica, Dragonor, Ecubalin, Epica, Epiron, Gaba-P, Gabanext, Gabarol, Gabica, Gablin, Gablovac, Gabrika, Gavin, Gialtyn, Glonervya, Helimon, Hexgabalin, Irenypathic, Kabian, Kemirica, Kineptia, Lecaent, Lingabat, Linprel, Lyribastad, Lyric, Lyrica, Lyrineur, Lyrolin, Lyzalon, Martesia, Maxgalin, Mystika, Neuragabalin, Neugaba, Neurega, Neurica, Neuristan, Neurolin, Neurovan, Neurum, Newrica, Nuramed, Paden, Pagadin, Pagamax, Painica, Pevesca, PG, Plenica, Pragiola, Prebalin, Prebanal, Prebel, Prebictal, Prebien, Prefaxil, Pregaba, Pregabalin, Pregabalina, Pregabaline, Prégabaline, Pregabalinum, Pregabateg, Pregaben, Pregabid, Pregabin, Pregacent, Pregadel, Pregagamma, Pregalex, Pregalin, Pregalodos, Pregamid, Pregan, Preganerve, Pregastar, Pregatrend, Pregavalex, Pregdin Apex, Pregeb, Pregobin, Prejunate, Prelin, Preludyo, Prelyx, Premilin, Preneurolin, Prestat, Pretor, Priga, Provelyn, Regapen, Resenz, Rewisca, Serigabtin, Symra, Vronogabic, Xablin, and Xil.[89] WP

It is marketed as a combination drug with mecobalamin under the brand names Agemax-P, Alphamix-PG, Freenerve-P, Gaben, Macraberin-P, Mecoblend-P, Mecozen-PG, Meex-PG, Methylnuron-P, Nervolin, Nervopreg, Neurica-M, Neuroprime-PG, Neutron-OD, Nuroday-P, Nurodon-PG, Nuwin-P, Pecomin-PG, Prebel-M, Predic-GM, Pregacent-M, Pregamet, Preganerv-M, Pregeb-M OD, Pregmic, Prejunate Plus, Preneurolin Plus, Pretek-GM, Rejusite, Renerve-P, Safyvit-PR, Vitcobin-P, and Voltanerv with Methylcobalamin and ALA by Cogentrix Pharma.[89] WP

In the US, Lyrica is marketed by Viatris after Upjohn was spun off from Pfizer.[90][91][92] WP

Pharmacology

Mechanism of action

Pregabalin is a member of the gabapentinoid class, also known as α₂δ ligands. Despite being a structural analog of γ-aminobutyric acid (GABA), pregabalin is inactive at GABA receptors and does not mimic GABA. Instead, its action involves binding to a specific site on the α₂δ-1 protein and reducing the release of excitatory neurotransmitters in synapses.[8][17][18][19][93] WP

Pregabalin does not directly block calcium channels (it is not a calcium channel blocker), as it does not bind to the ion conducting channel protein, called α1. However, in vitro studies show that pregabalin can reduce the normal traffic of calcium channels from intracellular sites (where they do not function) to membrane sites where they are functional.[4][17] WP

While the mechanism of action of pregabalin is not definitively characterized, its action in animal models of pain, seizures and anxiety requires binding to the α₂δ-1 protein. It has been found that this binding inhibits several actions of α₂δ-1 and also inhibits the release of excitatory neurotransmitters. These excitatory neurotransmitters include glutamate, norepinephrine (noradrenaline), serotonin, dopamine, substance P, and calcitonin gene-related peptide. By inhibiting the release of these neurotransmitters, pregabalin reduces excess activity of neuron networks, which helps alleviate symptoms and provides relief for patients experiencing pain, seizures, or other related symptoms.[18][94][95] WP

Pharmacodynamics

There are two drug-binding α₂δ subunits, α₂δ-1 and α₂δ-2, and pregabalin shows similar affinity for (and hence lack of selectivity between) these two sites. Pregabalin is selective in its binding to the α₂δ VGCC subunits and does not bind significantly to other known drug receptors.[17][19][96] WP

Despite the fact that pregabalin is a GABA analogue, it does not bind to GABA receptors, does not convert into GABA (γ-aminobutyric acid) or another GABA receptor agonist in vivo, and does not directly modulate GABA transport or metabolism. There is currently no evidence that the effects of pregabalin are mediated by any mechanism other than binding to the α₂δ-1 protein. In accordance, inhibition of α₂δ-1 proteins by pregabalin appears to be responsible for its anticonvulsant, analgesic, and anxiolytic effects in animal models.[20][96][97][98] WP

Recently, the α₂δ-1 protein has been found (independent of calcium channels) to associate directly with certain NMDA-type glutamate receptors, some AMPA-type glutamate receptors and also with the extracellular matrix protein, thrombospondin, and to modulate the function of these proteins. This has been proposed to contribute to the analgesic action of pregabalin animal models and in clinical use.[94] WP

The endogenous α-amino acids L-leucine and L-isoleucine, which closely resemble pregabalin and the other gabapentinoids in chemical structure, are apparent ligands of the α₂δ VGCC subunit with similar affinity as the gabapentinoids (e.g., IC₅₀=71 nM for L-isoleucine), and are present in human cerebrospinal fluid at micromolar concentrations (e.g., 12.9 μM for L-leucine, 4.8 μM for L-isoleucine). It has been theorized that they may be the endogenous ligands of the subunit and that they may competitively antagonize the effects of gabapentinoids. In accordance, while gabapentinoids like pregabalin and gabapentin have nanomolar affinities for the α₂δ subunit, their potencies in vivo are in the low micromolar range, and competition for binding by endogenous L-amino acids has been said to likely be responsible for this discrepancy.[18][98][99] WP

Pregabalin was found to possess 6-fold higher affinity than gabapentin for α₂δ subunit-containing VGCCs in one study. However, another study found that pregabalin and gabapentin had similar affinities for the human recombinant α₂δ-1 subunit (Kᵢ=32 nM and 40 nM, respectively). In any case, pregabalin is 2 to 4 times more potent than gabapentin as an analgesic and, in animals, appears to be 3 to 10 times more potent than gabapentin as an anticonvulsant.[97][100–103] WP

Absorption

Pregabalin is absorbed from the intestines by an active transport process mediated via the large neutral amino acid transporter 1 (LAT1, SLC7A5), a transporter for amino acids such as L-leucine and L-phenylalanine. Few (less than 10 drugs) are known to be transported by this transporter. Unlike gabapentin, which is transported solely by the LAT1, pregabalin seems to be transported by the LAT1 and by other carriers as well. The LAT1 is easily saturable, so the pharmacokinetics of gabapentin are dose-dependent, with diminished bioavailability and delayed peak levels at higher doses. In contrast, this is not the case for pregabalin, which shows linear pharmacokinetics and no saturation of absorption.[17][28][96][104][105] WP

The oral bioavailability of pregabalin is greater than or equal to 90% across and beyond its entire clinical dose range (75 to 600 mg/day). Food does not significantly influence the oral bioavailability of pregabalin. Pregabalin is rapidly absorbed when administered on an empty stomach, with a Tₘₐₓ (time to peak levels) of generally less than or equal to 1 hour at doses of 300 mg or less. Food has been found to substantially delay the absorption of pregabalin and to significantly reduce peak levels without affecting the bioavailability of the drug; Tₘₐₓ values for pregabalin of 0.6 hours in a fasted state and 3.2 hours in a fed state (5-fold difference), and the Cₘₐₓ is reduced by 25–31% in a fed versus fasted state.[17][28][106] WP

Distribution

Pregabalin crosses the blood–brain barrier and enters the central nervous system. However, due to its low lipophilicity, pregabalin requires active transport across the blood–brain barrier. The LAT1 is highly expressed at the blood–brain barrier and transports pregabalin across into the brain. 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 an orally administered dose of pregabalin is approximately 0.56 L/kg. Pregabalin is not significantly bound to plasma proteins (<1%).[28][96][104][106–109] WP

Metabolism

Pregabalin undergoes little or no metabolism. In experiments using nuclear medicine techniques, it was revealed that approximately 98% of the radioactivity recovered in the urine was unchanged pregabalin. The main metabolite is N-methylpregabalin.[17][28][106][110] WP

Pregabalin is generally safe in patients with liver cirrhosis.[111] WP

Elimination

Pregabalin is eliminated by the kidneys in the urine, mainly in its unchanged form. It has a relatively short elimination half-life, with a reported value of 6.3 hours. Because of its short elimination half-life, pregabalin is administered 2 to 3 times per day to maintain therapeutic levels. The kidney clearance of pregabalin is 73 mL/minute.[28][49][106] WP

As pregabalin clearance is directly proportional to creatinine clearance, renal impairment leads to drug accumulation and elevated plasma concentrations. Dose adjustment is therefore required in patients with a creatinine clearance below 60 mL/min, with progressively greater reductions recommended as renal function declines. Patients undergoing hemodialysis require supplemental dosing following each session, as a standard four-hour treatment reduces plasma pregabalin concentrations by approximately 50%.[112][113] WP

Chemistry

Formula

C8H17NO2 PC

CAS number

148553-50-8 PC

Molar mass (g/mol)

159.23 PC

IUPAC name (computed by PubChem)

(3S)-3-(aminomethyl)-5-methylhexanoic acid PC

SMILES

CC(C)C[C@@H](CC(=O)O)CN PC

InChIKey

AYXYPKUFHZROOJ-ZETCQYMHSA-N PC

PubChem CID

5486971

Pop culture

No references added yet.

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87. Other Decision: Pfizer Inc. (PFE) v. Teva Pharmaceuticals USA Inc., 12-1576, U.S. Court of Appeals for the Federal Circuit (Washington)
88. Other Pfizer's failed pregabalin patent appeal means NHS could reclaim £502m. November 14, 2018
89. Other Pregabalin international brands
90. Other Pfizer Completes Transaction to Combine Its Upjohn Business with Mylan. November 16, 2020
91. Other Lyrica
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113. Journal / agency These highlights do not include all the information needed to use LYRICA safely and effectively. See full prescribing information for LYRICA. LYRICA (pregabalin) Capsules, CVLYRICA (pregabalin) Oral Solution, CVInitial U.S. Approval: 2004

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