Thousands of GPs prompted to review pregabalin prescribing

Anastasia Tsirtsakis

17/03/2021 3:19:18 PM

GPs are being called to self-audit amid concerns over harmful and hazardous use of pregabalin in combination with opioids and benzodiazepines.

Safety concerns have led the Therapeutic Goods Administration to update pregabalin’s product and consumer medicine information to highlight the risks.

This article was updated on 18 March at 11.15am to change the picture as it originally depicted a prescription of pregabalin 50 mg, which is not available in Australia.

GPs across Australia this week started to receive a Pharmaceutical Benefits Scheme (PBS) Practice Review report on pregabalin from NPS MedicineWise, featuring individualised prescribing data on the anti-epileptic drug.
The review, according to NPS MedicineWise CEO Adjunct Associate Professor Steve Morris, is an opportunity for GPs to reflect on their prescribing habits, and on the diagnosis and management of their patients with neuropathic pain.
‘The practice review is one way NPS MedicineWise is continuing to support the best practice use of medicines and tests,’ he said.
The review follows an investigation by the Therapeutic Goods Administration (TGA) into continuing reports of misuse, abuse and dependence associated with pregabalin that led to an update of the drug’s product and consumer medicine information to highlight the risks.
An Australian study found a ten-fold increase in the rate of pregabalin-related ambulance attendances from 2012–18, with patients frequently misusing pregabalin with other sedating medicines.
More recently, on 19 January, the TGA’s Database of Adverse Event Notifications included 184 reports of suspected abuse, misuse or dependence with pregabalin, and 18 with gabapentin products. Of 111 fatal cases, 110 identified pregabalin as a suspected medicine.
Dr Milana Votrubec, Chair of RACGP Specific Interests Pain Management, told newsGP the practice review is a welcome opportunity.  
‘The examination video that’s been created in order to upskill GPs in delineating neuropathic pain … is very good and worthwhile, because unfortunately what’s been happening out there in the real world is that as soon as a patient said they had burning pain they were prescribed one of the gabapentinoids,’ she said.
‘Any kind of help in that regard would be, I hope, most welcomed by GPs because it’s sometimes hard to know what to do with neuropathic pain, as it’s not an easy concept to deal with.’
In response to insights provided from their own prescribing data, the review encourages GPs to reflect on how they can optimise use of pregabalin and minimise risks of misuse and high-risk combinations such as opioids and/or benzodiazepines.
Of all the patients prescribed pregabalin nationally in 2019–20, 47% also had a prescription for either an opioid or a benzodiazepine, and 19% had prescriptions for both.
Dr Votrubec says it is vital to have a current and accurate list of the patient’s medications when prescribing any medication.
‘I had the dubious privilege of having to look at the coroner’s reports from Victoria, whereby opioids were only one of several drugs, including pregabalin and benzodiazepine, with the finger firmly pointed directly at opioids,’ she said.
‘Now we’re starting to look at this more closely and say these people may have had problems with one of the gabapentinoids. The story then is, what else are they on?
‘Because it may well be that they’re on multiple medications, and perhaps have even gotten scripts from other places rather than the usual practice.
‘This in itself is a salutary reminder to GPs to actually check what their patients are taking currently.’
To help, Dr Votrubec says patient education is key to minimising risk of misuse and ensuring better outcomes.
‘A lot of the time a patient will take, let’s say, pregabalin and they’re prescribed a low dose, which is how you start out,’ she said. ‘They take it for a day or two, but unlike a paracetamol or an ibuprofen … which will give you instantaneous relief or at worst no relief, gabapentinoids don’t act quickly.
‘Patients will take a couple of days of low dose pregabalin and you’ll find them actually escalating the dose because there’s been no response. So they then take double the dose, which wasn’t prescribed in the first place.
‘Unless the GP finds the time to actually instruct the patient as to how to take these medications and how long it’s actually going to take effect, and that it is supported by the pharmacist who actually fills the script, you are going to find patients so-called “abusing” them, when in fact they’re not abusing so much as they’re actually trying to alleviate their pain by escalating the dose.’
To avoid such a scenario, Dr Votrubec suggests explaining to the patient that the medication is being started as ‘a trial’ that will need to be formally reviewed.  
‘We’re going to start low and go slow, understanding that it’ll take two to three weeks for the medications to actually kick in … to work against neuropathic pain, which presumably the GP has already ascertained that that’s probably the most likely diagnosis,’ she said.
‘Then review depending on the patient’s circumstances … every week or every two weeks, and whether the patient can be seen in that short space of time, and if it doesn’t work … there may be a need to escalate, provided that the patient is not becoming neurologically impaired by the medication.’
The PBS Practice Review on pregabalin is an approved RACGP Continuing Professional Development (CPD) activity.
‘The NPS MedicineWise practice review really should be regarded as an audit to ensure that our patients are getting the best and most efficacious medication for the diagnosis of neuropathic pain,' Dr Votrubec said.
‘If those patients who are taking pregabalin are improving, then that’s an endorsement that what we are prescribing is appropriate.’
NPS MedicineWise provides the following points for reflection:

  • For chronic neuropathic pain, consider a TCA (amitriptyline or nortriptyline) or an SNRI (duloxetine or venlafaxine) or a gabapentinoid (pregabalin or gabapentin) – base choice on individual patient factors and medicine properties
  • Advise patients of common adverse effects, and risk of dependency and misuse with pregabalin
  • For acute neuropathic pain, gabapentinoids may be preferred due to their faster onset of action, but their use may be limited by potential harms. Consider a TCA or SNRI if a gabapentinoid is not appropriate
  • Lidocaine 5% patches are preferred options for patients with localised neuropathic pain, particularly for older or frail patients and those on multiple medicines
  • Gabapentin, nortriptyline, duloxetine, venlafaxine and lidocaine are not available on the PBS for neuropathic pain
GPs can obtain further updated information about neuropathic pain and treatment options on the NPS MedicineWise website.
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Dr Slavko Doslo   18/03/2021 10:48:32 AM

Dear Anastasia Tsirtsakis

Pregabalin is fantastic medication when used for right conditions and come in 25 mg, 75 mg 150 mg and 300 mg
I " welcome 50 mg " new strength, ( please be careful promoting non existing strength, we are GP and have sharp eye)
So after Pregabalin 50 mg photo I did not even bother reading the article. As what can be correct after incorrect introduction