Anecdotally, it has been used with quite of bit of success as a substitute for BZDs (clonazepam, lorazepam, alprazolam, etc) in multiple indications including GAD. It seems to have 

Anecdotally, I worked with a patient with extremely severe anxiety who had not responded to other anxiolytics but did reasonably well on pregabalin. Unfortunately the patient had to stop taking it due to reduced kidney function and there was a significant ongoing deterioration in mood as a result of switching to another medication.

Thank you, Devin and Sarah.

I have prescribed it as a non-addicting sleep aid, 100-200 mg.How do you recommend prescribing it for anxiety?  Lewis Opler, MD, PhD

I am not a medic, working as cognitive behavioral therapist in the NHS and teaching Psychotherapy/Counseling, and only have anecdotal experience with my clients -  generally clients have reported pregabalin as ineffective for high levels of anxiety (incl. GAD, trauma-related anxiety and panic with agoraphobia), though in one important exception a methadone maintenance client regularly bought pregabalin (having tried it from a friend's Px) and swore it was the best thing for their anxiety ... their psychiatrist and GP refused to prescribe them in these circumstances - I suspect there's something more complex going on in the pharmacodynamics or -kinetics here ... maybe with GABA and/or µ ...

I second Mike's comment regarding pregabalin as an anxiolytic for pts being treated for Opioid Use Disorder (e.g. DSM 304.xx) whether on OST maintenance with methadone or buprenorphine, OR in an abstinence-based therapy.  Often clinicians are reluctant to prescribe BZDs for anxiety in that case although one could argue that harm reduction justifies it.  In any case, there is considerable ANECDOTAL evidence that pregabalin is being widely used not only as a BZD substitute (with less efficacy but less dependency), but also as a medication to treat those seeking to end dependence on BZDs, and also as a medication for those in PAWS (Post Acute Withdrawal Syndrome) from both alcohol and opioids.  Lewis, to address your dosing question, and again this is ANECDOTAL - your range sounds a bit low.  The FDA puts their maximum daily recommended dose at 600mg and I know of several prescribers who have had patients on doses of 1000mg/day for years.  If it weren't about to become generic (2018) in the US, I imagine Pfizer might fund some studies.  Alas, there is none that I have found to be of use.  I would suggest looking at mg/kg, but the little data we have suggests that is fully absorbed and the psychoactive metabolite makes it through the blood-brain barrier regardless of pt weight.  In any case, what I have heard might suggest that one should consider higher doses in individuals where suboptimal efficacy obtains.  200mg BID, TID, QID, are not uncommon prescriptions as far as I know.  And note that pregabilin is now available in 300mg capsule...suggesting that there is demand for pregabalin at a higher dosage range.  It is unfortunate that there is no RCT studying pregabalin for GAD and PAWS/opioid withdrawal/maintenance.  

I am planning to start low at 100 mg bid for a patient on Valium 5 mg tid; after a week I will try a cross taper, going down slowly on Valium while increasing pregabalin to 200 bid.

nb: there is no opioid or other substance abuse

Hi Lewis - I'm in Psychology so I'll leave opinions on prescribing to the better-informed. Following the discussion with great interest!

Hi Lewis - I'm in Psychology so I'll leave opinions on prescribing to the better-informed. Following the discussion with great interest!

Thanks, Sarah

Patient is on 100 mg bid of Lyrica

After 1/1/2016 I will begin a cross taper and see if I can taper and d/c Valium while raising Lyrica to 200 mg bid

HAPPY NEW YEAR!

Patient is now on Lyrica 100 mg bid.

After 1/1/2016 I will start lowering Valium while raising Lyrica to 200 mg MD.

HAPPY NEW YEAR'

Lewis, as I'm sure you know discontinuation of BZDs is extremely difficult.  Even 5mg diazepam TID is substantial if pt has been taking for a long duration.  Pregabalin should help with rebound anxiety etc. but per literature the pt will still experience some material discomfort.  I refer you to Prof Heather Ashton's (University of Newcastle, Institute of Neuroscience) website http://benzo.org.uk for some general guidelines.  Prof Ashton takes a rather dim view of BZDs, which many clinicians do not share, but again, ANECDOTALLY, her website (which advises first switching to diazepam, so that's taken care of, and then VERY SLOWLY reducing dosages) has helped many pts withdraw successfully.  You, and perhaps your pt as well, might find the site useful.

I have told my patient that this will be a lengthy process.

i am aware of AND agree with the work of Professor Ashton and appreciate your providing reference.

A combination of fluoxetine ( first 10 mg then 20) and Alprazolam (1 mg) x 1  work well

thank you

Also for more options, there is evidence from small randomized placebo-controlled augmentation studies suggesting that augmentation of antidepressants with antipsychotic drugs (olanzapine, quetiapine, and risperidone) may be beneficial,though the evidence for quetiapine augmentation is inconsistent and uncertain for ziprasidone augmentation.

see https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3699256/

see also page 10 of bap guidelines below

http://www.bap.org.uk/pdfs/AnxietyGuidelines2014.pdf

which suggests that augmentation with quetiapine might be useful acutely and in relapse  prevention.

"Pregabalin has proven efficacy in both acute treatment and prevention of relapse in generalised anxiety disorder, and social anxiety disorder".

Dr. Sood - Since Lewis put this question in the realm of *anecdotal* evidence as well as traditional EBM/PCT etc, I would note some serious downsides to the atypical antipsychotics, which I'm sure come as no surprise to you (1) pts generally report dissatisfaction with the "feeling" of olanzapine, quetiapine, and risperidone as compared to that of BZDs (most preferable) and pregabalin (next most preferable) - while they certainly have therapeutic value, the atypical antipsychotics are disliked by many patients, and thus result in much lower adherence -- they control anxiety at a cost generally not attributed to gabaergics.  (2) The jury is still out on the risks of permanent dyskinesia from all three atypical mentioned -- little research here, but litigation aplenty.  For *some* patients, I agree that atypicals can be used to manage anxiety.  For many, and ANECDOTALLY, for very high functioning pts, the "downside" to the atypicals outweighs the "upside".  That is why I think PGN, as a weaker (less addictive, less dependence-forming) gabaergic, has so much promise - it is well-tolerated, has high adherence, and as your quote states, seems to be effective in keeping pts from "relapsing" (either to BZDs or to GAD or both) after they are weaned from BZDs.  I would also suggest looking at the extensive literature on gabapentin, which I believe has a similar mechanism of action as PGN but is even weaker.  It may be appropriate for some pts with GAD and or BZD dependency.