I have received a letter from Leicester hospital following my consultation with a neurology Registrar.
I am on 1100mg of Gabapentin suggested dose of Pregabalin is 75mg at 6.00pm and 75mg 30 minutes before bedtime, can be uptitrated as required. Does this sound right? I have zero confidence in registrar so would like some advice. It also states on letter that if Pregabalin isn’t effective other options would be clonazepam ( as a side note she states that this can cause sedation and can be associated with augmentation), or oxycodone with naloxone combination.
I know nothing about the alternative medicines she suggests? Are they effective?
Thanks in advance.
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Elsie77
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Sounds good. Usually, pregabalin is taken in one dose as it's fully absorbed, unlike gabapentin.
You can asjust the timing to suit your symptoms, so you could try 50mg 2 hours before bed and 100mg at bedtime, or 75mg 2 hour's before bed and 75mg at bedtime.Hopefully the side effects will be less for you than on gabapentin.
Clonazepam does NOT cause augmentation. Augmentation is a severe worsening of RLS itself. I can only assume the registrar means that Clonazepam loses effectiveness,like most benzodiazepenes.
Targinact is licensed for RLS and is Oxycontin and naloxone. The naloxone stops absorption in the gut and so helps prevent opioid induced constipation.
It works well for many but can sometimes cause mini opioid withdrawals, in which case, taking it every 6 hours or every 4 hours at lower doses can help. If preg abalin works, you won't need to consider Oxycontin for now.
Thanks, my doctor has only prescribed 75mg tablets which I think is shortsighted as hospital did say to increase if needed to. Do you know what size tablets are available? I can then ask Dr to prescribe a range if I need to.
Have you already started the pregabalin? If not I wouldn't add that much all at once but would add 25 mg every couple of days until you find the dose that works for you, especially since you had side effects when you tried to increase the gabapentin above 1100 mg. Clonazepam cannot cause augmentation but because it has a half life of 40 hours can cause next day drowsiness. Also, Clonazepam doesn't really help RLS, it mainly helps you sleep. If the gabapentin and pregabalin don't work the oxycodone with naloxone combination should. If you ever need to come off the gabapentin or pregabalin do so very slowly like 25 mg pregabalin or 100 mg gabapentin every 2 weeks to avoid withdrawal effects. If you come off it slowly enough you won't have any.
Sue, she's making a straight switch from gabapentin. Her pharmacist has confirmed a straight switch is the way to go. Otherwise, there will be RLS as she reduces gabapentin & then slowly increases the pregabalin.
Thanks Sue and everyone who has responded. I don’t particularly want to split the dose so do you think it’s better to take 100mg ? starting dose at 6 pm and drop the bedtime one?
Take it all 1 to 2 hours before bedtime as that is when you need it unless your symptoms occur earlier. However take the 150 mg you have been prescribed not 100 mg because that is reducing the dose from what you were taking on gabapentin and you will have withdrawal effects. To get the equivalent dose one divides the gabapentin amount by 6, so that would be 183 mg so your doctor has already reduced the dose you will be taking.
It sounds like your neurologist is better than most. For the first step she is staying with an alpha 2 delta ligand and looking at swapping pregabalin for Gabapentin. These are essentially the same drug, but the dosages are quite different and some people tolerate one better than the other. The starting dose of 150mg is less than the 300mg often recommended for pregabalin but that allows you to increase gradually and see if you get the benefits earlier with fewer possible side effects.
As the next step if required, she’s suggesting clonazepam which does help some people, although as it has been mentioned, it can cause problems with feeling groggy the next day as it has a long time span.
Lastly if this doesn’t help then oxycodone is a different type of drug, an opioid, which often helps although people do sometimes need to try alternatives like Buprenorphine to find one which suits them.
All this is in line with the Mayo Algorithm which is the current best practice advice. Good luck.
I also went from Gabapentin to Pregabalin (years ago). Pregabalin was definitly preferable to gabapentin for me, it was much more consistent. That being said, I am off Pregabalin and glad that all the side effects are gone. I would still prefer Pregabalin to RLS.
The following information is taken directly from the document which I reference nearly daily in my practice. It is entitled: The Management of Restless Legs Syndrome: An Updated Algorithm.
It is co-authored by arguably, the most frequently referenced researchers in the world, namely: Michael H. Silber, MBChB; Mark J. Buchfuhrer, MD; Christopher J. Earley, MBBCh, PhD; Brian B. Koo, MD; Mauro Manconi, MD; and John W. Winkelman, MD, PhD, for the Scientific and Medical Advisory Board of the Restless Legs Syndrome Foundation
"Gabapentin and pregabalin (Table 1) are usually administered as once- or twice-daily doses in the late afternoon or evening or before sleep. It is recommended to start treatment 1 to 2 hours before usual onset of symptoms."
"Treatment should commence at 300 mg of gabapentin (100 mg in patients older than 65 years) or 75 mg of pregabalin daily (50 mg in patients older than 65 years) and be increased every few days as needed.
"Most RLS patients require 1200 to 1800 mg of gabapentin daily, but doses up to 3600 mg daily can be used."
"Effective pregabalin doses are usually in the range of 150 to 450 mg daily."
Typically, you will not need the maximum doses of the drugs but rarely, will your RLS be controlled with minimal levels either. DO NOT BE STINGY WITH YOURSELF and MOST SIDE-EFFECTS, IF ANY, TYPICALLY ARE MINIMAL AND SUBSIDE OVER TIME.
Lastly, iron supplementation is typically needed. The above-referenced article is also quite clear on what is required for adequate iron levels, specifically, > SERUM FERRITIN (75ng/mL) and TRANSFERRIN SATURATION (> 45%).
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