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LYRICA (Pregabalin)

Health Professional Information

SUMMARY PRODUCT INFORMATION

Route of Administration

DosageForm / Strength

All Nonmedicinal Ingredients

Oral

Capsules, 25 mg,

50 mg, 75 mg,

100§ mg, 150 mg, 200§ mg, 225 mg, 300mg

Lactose monohydrate, maize starch, and talc
 

Capsule shells contain gelatin and titanium dioxide. In addition, orange capsule shells contain red iron oxide. White capsule shells contain sodium lauryl sulphate and colloidal silicon dioxide.

§ Not commercially available in Canada

Indications And Clinical Use

Adults

LYRICA (pregabalin) is indicated for the management of neuropathic pain associated with:

  • Diabetic peripheral neuropathy and
  • Postherpetic neuralgia

LYRICA is indicated for the management of neuropathic pain associated with spinal cord injury.

LYRICA is indicated for the management of pain associated with fibromyalgia.

The efficacy of LYRICA in the management of pain associated with fibromyalgia for up to 6 months was demonstrated in a placebo-controlled trial in patients who had initially responded to LYRICA during a 6-week open-label phase.

Geriatrics (>65 years of age): Pregabalin oral clearance tended to decrease with increasing age. This decrease in pregabalin oral clearance is consistent with age-related decreases in creatinine clearance. Reduction of pregabalin dose may be required in patients who have age-related compromised renal function (see WARNINGS AND PRECAUTIONS, Geriatrics (>65 years of age)).

Pediatrics (<18 years of age): The safety and efficacy of pregabalin in pediatric patients (<18 years of age) have not been established and its use in this patient population is not indicated (see WARNINGS AND PRECAUTIONS, Pediatrics (<18 years of age)).

Contraindications

Patients who are hypersensitive to pregabalin or to any ingredient in the formulation or component of the container.

Warnings And Precautions

Angioedema

There have been post-marketing reports of angioedema in patients, some without reported previous history/episode(s), during initial/acute and chronic treatment with LYRICA (pregabalin). Specific symptoms included swelling of the face, mouth (tongue, lips, and gums), neck, throat, and larynx/upper airway. There have been reports of life-threatening angioedema with respiratory compromise requiring emergency treatment. Some of these patients did not have reported previous history/episode(s) of angioedema. LYRICA should be immediately discontinued in patients with these symptoms. During the pre-marketing assessment of pregabalin in clinical trials, angioedema was reported as a rare reaction (see ADVERSE REACTIONS, Less Common Clinical Trial Adverse Reactions and Post-Marketing Adverse Drug Reactions).

Caution should be exercised when prescribing LYRICA to patients with previous history/episode(s) of angioedema and related events. In addition, patients who are taking other drugs associated with angioedema (eg, ACE-inhibitors) may be at increased risk of developing this condition.

Hypersensitivity

There have been postmarketing reports of hypersensitivity reactions (eg, skin redness, blisters, hives, rash, dyspnea, and wheezing). Pregabalin should be discontinued immediately if such symptoms occur (see Post-Marketing Adverse Drug Reactions).

Renal Failure

In both clinical trials of various indications and post-marketing database, there are reports of patients, with or without previous history, experiencing renal failure while receiving pregabalin alone or in combination with other medications. Discontinuation of pregabalin should be considered as it has shown reversibility of this event in some cases. Caution is advised when prescribing pregabalin to the elderly or those with any degree of renal impairment (see Special Populations, Renal; Abrupt or Rapid Discontinuation; ADVERSE REACTIONS, Post- Marketing Adverse Drug Reactions; and DOSAGE AND ADMINISTRATION).

Tumorigenic Potential

In standard preclinical in vivo lifetime carcinogenicity studies of pregabalin, a high incidence of hemangiosarcoma was identified in two different strains of mice (see Preclinical Toxicology). The clinical significance of this finding is uncertain. Clinical experience during pregabalin’s premarketing development provides no direct means to assess its potential for inducing tumors in humans.

In clinical studies across various patient populations, comprising 6396 patient-years of exposure in 8666 patients ranging in age from 12 to 100 years, new or worsening-preexisting tumors were reported in 57 patients. The most common malignant tumor diagnosed was skin carcinoma (17 patients) followed by breast carcinoma (8 patients), prostatic carcinoma (6 patients), carcinoma not otherwise specified (6 patients), and bladder carcinoma (4 patients). Without knowledge of the background incidence and recurrence in similar populations not treated with LYRICA, it is impossible to know whether the incidence seen in these cohorts is or is not affected by treatment.

Ophthalmological Effects

In controlled studies, pregabalin treatment was associated with vision-related adverse events such as blurred vision (amblyopia) [6% pregabalin and 2% placebo] and diplopia (2% pregabalin and 0.5% placebo). Approximately 1% of pregabalin-treated patients discontinued treatment due to vision-related adverse events (primarily blurred vision). Of the patients who did not withdraw, the blurred vision resolved with continued dosing in approximately half of the cases (see Post-Marketing Adverse Drug Reactions).

Prospectively planned ophthalmologic testing, including visual acuity testing, formal visual field testing and dilated funduscopic examination, was performed in over 3600 patients. In these patients, visual acuity was reduced in 7% of patients treated with pregabalin, and 5% of placebo- treated patients. Visual field changes were detected in 13% of pregabalin-treated, and 12% of placebo-treated patients. Funduscopic changes were observed in 2% of pregabalin-treated and 2% of placebo-treated patients. At this time, clinical significance of the ophthalmologic findings is unknown.

Patients should be informed that if changes in vision occur, they should notify their physician. If visual disturbance persists, further assessment, including discontinuation of pregabalin, should be considered. More frequent assessments should be considered for patients who are already routinely monitored for ocular conditions.

Peripheral Edema

LYRICA may cause peripheral edema. In controlled peripheral neuropathic pain and fibromyalgia clinical trials, pregabalin treatment caused peripheral edema in 9% of patients compared with 3% of patients in the placebo group. In these studies, 0.7% of pregabalin patients and 0.3% of placebo patients withdrew due to peripheral edema (see ADVERSE REACTIONS, Peripheral Edema).

In controlled clinical trials of up to 13 weeks in duration of patients without clinically significant heart or peripheral vascular disease, there was no apparent association between peripheral edema and cardiovascular complications such as hypertension or congestive heart failure. In the same trials, peripheral edema was not associated with laboratory changes suggestive of deterioration in renal or hepatic function.

Higher frequencies of weight gain and peripheral edema were observed in patients taking both LYRICA and a thiazolidinedione antidiabetic agent compared to patients taking either drug alone. The majority of patients using thiazolidinedione antidiabetic agents in the overall safety database were participants in studies of pain associated with diabetic peripheral neuropathy. In this population, peripheral edema was reported in 3% (2/60) of patients who were using thiazolidinedione antidiabetic agents only, 8% (69/859) of patients who were treated with pregabalin only, and 19% (23/120) of patients who were on both pregabalin and thiazolidinedione antidiabetic agents. Similarly, weight gain was reported in 0% (0/60) of patients on thiazolidinediones only; 4% (35/859) of patients on pregabalin only; and 7.5% (9/120) of patients on both drugs.

As the thiazolidinedione class of antidiabetic drugs can cause weight gain and/or fluid retention, possibly exacerbating or leading to heart failure, care should be taken when co-administering LYRICA and these agents.

Congestive Heart Failure

In controlled clinical studies, events of congestive heart failure were reported at an infrequent rate (between 0.1% and 1%; see ADVERSE REACTIONS, Less Common Clinical Trial Adverse Reactions).

There have been post-marketing reports of congestive heart failure in some patients receiving pregabalin (see ADVERSE REACTIONS, Post-marketing Adverse Drug Reactions). Although this adverse reaction has mostly been observed in elderly cardiovascular compromised patients during pregabalin treatment for a neuropathic pain indication, some cases have occurred in patients without reported edema or previous history of cardiovascular disease. Pregabalin should be used with caution in these patients. Discontinuation of pregabalin may resolve the reaction.

Serious Skin Reactions

There have been very rare post-marketing reports of serious cutaneous reactions, including Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), dermatitis exfoliative, bullous skin reactions, and erythema multiforme in patients treated with LYRICA (see Post- Market Adverse Drug Reactions). Post-market reporting rate is generally accepted to be an underestimate due to under-reporting. Most of the reports were in patients taking concomitant medications also associated with the potential development of these serious skin reactions. Therefore, in most cases, causality in relation to LYRICA could not be clearly established. Patients should be advised that if they experience a skin rash, they should discontinue LYRICA treatment and contact their physician for assessment and advice.

Gastrointestinal

There have been post-marketing reports of events related to reduced lower gastrointestinal tract function (eg. intestinal obstruction, paralytic ileus, and constipation) in patients, some without reported previous history/episode(s), during initial/acute and chronic treatment with LYRICA, primarily in combination with other medications that have the potential to produce constipation. Some of these events were considered serious and required hospitalization. In a number of instances, patients were taking opioid analgesics including tramadol.

Caution should be exercised when LYRICA and opioid analgesics are used in combination, and measures to prevent constipation may be considered, especially in female patients and elderly as they may be at increased risk of experiencing lower gastrointestinal-related events (see ADVERSE REACTIONS, Post-Marketing Adverse Drug Reactions).

Weight Gain

LYRICA may cause weight gain. In pregabalin-controlled peripheral neuropathic pain and fibromyalgia clinical trials with durations of up to 14 weeks, a gain of 7% or more over baseline weight was observed in 8% of pregabalin-treated patients and 3 % of placebo-treated patients. Few patients treated with pregabalin (0.6%) withdrew from controlled trials due to weight gain (see ADVERSE REACTIONS, Weight Gain).

Pregabalin-associated weight gain was related to dose and duration of exposure. Pregabalin- associated weight gain did not appear to be associated with baseline BMI, gender, or age. Weight gain was not limited to patients with edema and was not necessarily due to edema-related events (see WARNINGS AND PRECAUTIONS, Peripheral Edema).

Although weight gain was not associated with clinically important changes in blood pressure in short-term controlled studies, the long-term cardiovascular effects of pregabalin-associated weight gain are unknown.

Among diabetic patients, pregabalin-treated patients gained an average of 1.6 kg (range: -16 to 16 kg), compared to an average 0.3 kg (range: -10 to 9 kg) weight gain in placebo patients. In a cohort of 333 diabetic patients who received pregabalin for at least 2 years, the average weight gain was 5.2 kg.

In the controlled fibromyalgia clinical trials, 10.7% of pregabalin-treated patients experienced weight gain of 7% or greater compared to 4.9% of placebo-treated patients. Pregabalin-treated patients gained an average of 1.7 Kg compared to an average of 0.7 Kg weight gain in placebo patients.

While the effects of pregabalin-associated weight gain on glycemic control have not been systematically assessed, in controlled and longer-term open label clinical trials with diabetic patients, pregabalin treatment did not appear to be associated with loss of glycemic control (as measured by HbA1C).

Dizziness and Somnolence

LYRICA may cause dizziness and somnolence. In controlled peripheral neuropathic pain and fibromyalgia studies, pregabalin caused dizziness in 32% of patients compared to 8% in placebo. Somnolence was experienced by 17% and 4% of the patients treated with pregabalin and placebo, respectively. These events begin shortly after the initiation of therapy and generally occur more frequently at higher doses. In these studies, dizziness and somnolence led to withdrawal of 5% (placebo: 0.5%) and 3% (placebo: 0.1%) of the pregabalin-treated patients, respectively. For the remaining patients who experienced these events, dizziness and somnolence persisted until the last dose of pregabalin in 35% and 49% of the patients, respectively (see ADVERSE REACTIONS, Tables 2, 4, and 11, and Post-Marketing Adverse Drug Reactions).

Accordingly, patients should be advised not to drive or operate complex machinery or engage in other hazardous activities until they have gained sufficient experience on pregabalin to gauge whether or not it affects their mental and/or motor performance adversely (see Part III: CONSUMER INFORMATION).

Abrupt or Rapid Discontinuation

Following abrupt or rapid discontinuation of pregabalin, some patients reported symptoms including insomnia, nausea, headache, anxiety, hyperhidrosis, and diarrhea. Pregabalin should be tapered gradually over a minimum of one week rather than discontinued abruptly (see ADVERSE REACTIONS, Adverse Events Following Abrupt or Rapid Discontinuation).

Convulsions, including status epilepticus and grand mal convulsions, have occurred in non- epileptic patients during treatment with LYRICA or after abrupt discontinuation (see ADVERSE REACTIONS, Post-Marketing Adverse Drug Reactions).

Encephalopathy

There have been serious post-marketing reports of encephalopathy, mostly in patients with underlying conditions that may precipitate encephalopathy. Some cases were reported in patients with a history of kidney or liver disease. Since there have been rare reports of renal failure with LYRICA, specific caution should be exercised when prescribing LYRICA to the elderly with age-related compromised renal function and patients with kidney disease or risk factors for renal failure (see WARNINGS AND PRECAUTIONS, Renal Failure and ADVERSE REACTIONS, Post-Marketing Adverse Drug Reactions).

Suicidal Behaviour and Ideation

There have been post-marketing reports of suicide-related events, including completed suicide, suicide attempt, and suicidal ideation in patients treated with LYRICA for a variety of indications such as neuropathic pain, fibromyalgia, etc. In some of these reports, underlying psychiatric disorders may have contributed to the event. The mechanism of this risk is not known. Patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients should be encouraged to report any distressing thoughts or feelings at anytime to their healthcare professional (see ADVERSE REACTIONS, Post-Marketing Adverse Drug Reactions).

Sexual Function/Reproduction

Impairment of Male Fertility

Preclinical Data

In fertility studies in which male rats were orally administered pregabalin (50 to 2500 mg/kg) prior to and during mating with untreated females, a number of adverse reproductive and developmental effects were observed. These included decreased sperm counts and sperm motility, increased sperm abnormalities, reduced fertility, increased preimplantation embryo loss, decreased litter size, decreased fetal body weights, and an increased incidence of fetal abnormalities. Effects on sperm and fertility parameters were reversible in studies of this duration (3-4 months). The no-effect dose for male reproductive toxicity in these studies (100 mg/kg) was associated with a plasma pregabalin exposure (AUC) approximately 3 times human exposure at the maximum recommended dose (MRD) of 600 mg/day.

In addition, adverse effects on reproductive organ (testes, epididymides) histopathology were observed in male rats exposed to pregabalin (500 to 1250 mg/kg) in general toxicology studies of 4 weeks or greater duration. The no-effect dose for male reproductive organ histopathology in rats (250 mg/kg) was associated with a plasma exposure approximately 8 times human exposure at the MRD.

In a fertility study in which female rats were given pregabalin (500, 1250, or 2500 mg/kg) orally prior to and during mating and early gestation, disrupted estrous cyclicity and an increased number of days to mating were seen at all doses, and embryolethality occurred at the highest dose. The low dose in this study produced a plasma exposure approximately 9 times that in humans receiving the MRD. A no-effect dose for female reproductive toxicity in rats was not established. The clinical significance of female fertility findings in animals is unknown.

Human Data

In a double-blind, placebo-controlled clinical trial to assess the effect of pregabalin on sperm motility, 30 healthy male subjects were exposed to pregabalin 600 mg/day for 3 months (one complete sperm cycle). Pregabalin did not exhibit significant detrimental effects on the reproductive function of healthy male subjects, as measured by semen analysis, when compared with placebo (n = 16). However, due to the small sample size and short-term exposure to pregabalin (only one complete sperm cycle), no conclusions can be made regarding possible reproductive effects of pregabalin during long-term exposure. Effects on other male reproductive parameters in humans have not been adequately studied.

Special Populations

Renal

There have been reports of patients, with or without previous history, experiencing renal failure while receiving pregabalin alone or in combination with other medications. Discontinuation of pregabalin showed reversibility of this event in some cases (see WARNINGS AND PRECAUTIONS; ADVERSE REACTIONS, Post-Marketing Adverse Drug Reactions; and DOSAGE AND ADMINISTRATION). Because pregabalin is eliminated primarily by renal excretion, the dose of pregabalin should be adjusted as noted for elderly patients or those with renal impairment (see ACTION AND CLINICAL PHARMACOLOGY and DOSAGE AND ADMINISTRATION).

Adjustment of Dose in Renally-Impaired Patients
In patients with a medical history of significant renal insufficiency, daily dosages should be reduced accordingly (see Table 13 in DOSAGE AND ADMINISTRATION, Dosing Considerations).

Pregnancy

Preclinical Data
Pregabalin was not teratogenic in mice, rats, or rabbits. Pregabalin induced fetal toxicity in rats and rabbits at ≥ 39 times the mean human exposure at the maximum recommended clinical dose of 600 mg/day [AUC(0-24) of 123 μg∙hr/mL]. In the prenatal-postnatal toxicity study, pregabalin induced offspring developmental toxicity in rats at ≥5 times the maximum recommended human exposure. No developmental effects occurred at 2 times the maximum recommended human exposure (see TOXICOLOGY).

Human Data

Pregnant Women
There are no adequate and well-controlled studies in pregnant women. Pregabalin should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Patients should be encouraged to enroll in the North American Antiepileptic Drug (NAAED) Pregnancy Registry if they become pregnant. This registry is collecting information about the safety of anticonvulsant medications that can be taken by women during pregnancy to treat disorders such as epilepsy, mood disorder, and chronic pain. The primary goal is to determine the frequency of major malformations, such as heart defects, spina bifida and cleft lip, in the infants exposed during pregnancy to anticonvulsant drugs. To enroll, patients can call the toll-free number, 1-888-233-2334. Information on the registry can be also found at the website http://www.aedpregnancyregistry.org/ (see WARNINGS AND PRECAUTIONS, Patient Counselling Information).

Labour and Delivery
The effects of pregabalin on labour and delivery in pregnant women are unknown. In the prenatal-postnatal study in rats, pregabalin prolonged gestation and induced dystocia at exposures ≥47 times the mean human exposure [AUC(0-24) of 123 μg∙hr/mL] at the maximum recommended clinical dose of 600 mg/day (see TOXICOLOGY).

Nursing Women
Pregabalin is excreted in the milk of lactating women. As the safety of pregabalin in infants is not known, breast-feeding is not recommended during treatment with pregabalin. A decision must be made whether to discontinue breast-feeding or to discontinue from pregabalin therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the women (see TOXICOLOGY). Patients should be advised to notify their physician if they are breast-feeding.

The pharmacokinetics of 150 mg pregabalin given every 12 hours (300 mg daily dose) was evaluated in 10 lactating women who were at least 12 weeks postpartum. Pregabalin was excreted into breast milk with average peak and steady-state concentrations approximately 53 and 76% of those in maternal plasma, respectively. The estimated average daily infant dose of pregabalin from breast milk (assuming mean milk consumption of 150 mL/kg/day) was 0.31 mg/kg/day, which on a mg/kg basis would be approximately 7% of the total maternal daily dose.

Pediatrics (<18 years of age)
The safety and efficacy of pregabalin in pediatric patients (<18 years of age) have not been established.

Geriatrics (>65 years of age)
Of the 1831 patients who received pregabalin in neuropathic pain studies, 528 were 65 to 74 years of age, and 452 were 75 years of age or older. No significant differences in efficacy were observed between these patients and younger patients. Pregabalin oral clearance tended to decrease with increasing age. This decrease in pregabalin oral clearance is consistent with age- related decreases in creatinine clearance. Reduction of pregabalin dose may be required in patients who have age-related compromised renal function. In general, the incidence of adverse events did not increase with age.

Creatine Kinase Elevations
Pregabalin treatment was associated with creatine kinase elevations. Mean changes in creatine kinase from baseline to the maximum value were 60 U/L for pregabalin-treated patients and 28 U/L for the placebo patients. In all controlled trials across multiple patient populations, 2% of patients on pregabalin and 1% of placebo patients had a value of creatine kinase at least three times the upper limit of normal. Three pregabalin-treated subjects had events reported as rhabdomyolysis in premarketing clinical trials. The relationship between these myopathy events and pregabalin is not completely understood because the cases had documented factors that may have caused or contributed to these events. Prescribers should instruct patients to promptly report unexplained muscle pain, tenderness, or weakness, particularly if these muscle symptoms are accompanied by malaise or fever. Pregabalin treatment should be discontinued if myopathy is diagnosed or suspected or if markedly elevated creatine kinase levels occur.

Laboratory Changes, Decreased Platelet Count
Pregabalin treatment was associated with a decrease in platelet count. Pregabalin-treated subjects experienced a mean maximal decrease in platelet count of 20 x 103/mL, compared to 11 x 103/μL in placebo patients. In the overall database of controlled trials, 2% of placebo patients and 3% of pregabalin patients experienced a potentially clinically significant decrease in platelets, defined as 20% below baseline value and < 150 x 103/μL.

In randomized controlled trials, pregabalin was not associated with an increase in bleeding related adverse events.

ECG Changes, PR Interval Prolongation
Pregabalin treatment was associated with mild PR interval prolongation. In analyses of clinical trial ECG data, the mean PR interval increase was 3-6 msec at pregabalin doses ≥ 300 mg/day. This mean change difference was not associated with an increased risk of PR increase ≥ 25% from baseline, an increased percentage of subjects with on-treatment PR >200 msec, or an increased risk of adverse events of second or third degree AV block.

Patient Counselling Information

Patients receiving LYRICA should be given the following instructions by the physician:

  1. Angioedema: Patients should be advised that LYRICA may cause angioedema, with swelling of the face, mouth (lip, gum, tongue) and neck (larynx and pharynx) that can lead to life-threatening respiratory compromise. Instruct patients to discontinue LYRICA and immediately seek medical care if they experience these symptoms.
  2. Hypersensitivity: Patients should be advised that LYRICA has been associated with hypersensitivity reactions such as wheezing, dyspnea, rash, hives, and blisters. Instruct patients to discontinue LYRICA and immediately seek medical care if they experience these symptoms.
  3. Suicidal Behaviour and Ideation: Patients, their caregivers, and families should be counselled to monitor for signs of suicidal ideation and behaviours and should be encouraged to report any distressing thoughts or feelings at anytime to their healthcare professional.
  4. Dizziness and Somnolence: Patients should be counseled that LYRICA may cause dizziness, somnolence, blurred vision and other CNS signs and symptoms. Accordingly, they should be advised not to drive, operate complex machinery, or engage in other hazardous activities until they have gained sufficient experience on pregabalin to gauge whether or not it affects their mental, visual, and/or motor performance adversely.
  5. Edema and Weight Gain: Patients should be counseled that LYRICA may cause edema and weight gain. Patients should be advised that concomitant treatment with LYRICA and a thiazolidinedione antidiabetic agent may lead to an additive effect on edema and weight gain. For patients with preexisting cardiac conditions, this may increase the risk of heart failure.
  6. Abrupt or Rapid Discontinuation: Patients should be advised to take LYRICA as prescribed. Abrupt or rapid discontinuation may result in insomnia, nausea, headache, anxiety, hyperhidrosis, or diarrhea.
  7. Visual Disturbances: Patients should be counseled that LYRICA may cause visual disturbances. Patients should be informed that if changes in vision occur, they should notify their physician (see WARNINGS AND PRECAUTIONS, Ophthalmologic Effects).
  8. Muscle Pain, Tenderness or Weakness: Patients should be instructed to promptly report unexplained muscle pain, tenderness, or weakness, particularly if accompanied by malaise or fever.
  9. Concomitant Treatment with CNS Depressants, Alcohol: Patients who require concomitant treatment with central nervous system depressants such as opiates or benzodiazepines should be informed that they may experience additive CNS side effects, such as somnolence.

    In post-marketing experience, there are reports of respiratory failure and coma in patients taking pregabalin alone or in combination with other CNS depressants.

    Patients should be told to avoid consuming alcohol while taking LYRICA, as LYRICA may potentiate the impairment of motor skills and sedation of alcohol.
  10. Pregnant Women: Patients should be instructed to notify their physician if they become pregnant or intend to become pregnant during their therapy, and to notify their physician if they are breast-feeding or intend to breast-feed during therapy.

    Patients should be encouraged to enroll in the North American Antiepileptic Drug Pregnancy Registry (NAAED) if they become pregnant. This registry is collecting information about the safety of anticonvulsant medications that can be taken by women during pregnancy to treat disorders such as epilepsy, mood disorder, and chronic pain. To enroll, patients can call the toll free number 1-888-233-2334. Information on the registry can also be found at the website http://www.aedpregnancyregistry.org/ (see WARNINGS AND PRECAUTIONS; Special Populations, Pregnant Women).
  11. Animal Studies in Male Reproduction: Men being treated with LYRICA who plan to father a child should be informed of the potential risk of male-mediated teratogenicity. In preclinical studies in rats, pregabalin was associated with an increased risk of male- mediated teratogenicity (see WARNINGS AND PRECAUTIONS, Sexual Function/Reproduction). The clinical significance of this finding is uncertain.
  12. Skin: Diabetic patients should be instructed to pay particular attention to skin integrity while being treated with LYRICA. Some animals treated with pregabalin developed skin ulcerations, although no increased incidence of skin lesions associated with LYRICA was observed in clinical trials (see WARNINGS AND PRECAUTIONS, Preclinical Toxicology).

Patients should be informed of the availability of a patient information leaflet, and they should be instructed to read the leaflet prior to taking LYRICA.

Preclinical Toxicology

Carcinogenesis
Dose-dependent increase in the incidence of malignant vascular tumors (hemangiosarcomas) was observed in two strains of mice (B6C3F1 and CD-1) given pregabalin (200, 1000, or 5000 mg/kg) in the diet for two years. Plasma pregabalin exposure (AUC) in mice receiving the lowest dose that increased hemangiosarcomas was approximately equal to the human exposure at the maximum recommended dose (MRD) of 600 mg/day. A no-effect dose for induction of hemangiosarcomas in mice was not established. In an investigative study in female B6C3F1 mice, chronic treatment (24 months) with pregabalin at 1000 mg/kg caused an increased incidence of hemangiosarcoma, consistent with previous studies, but not at 50 or 200 mg/kg. Discontinuation of treatment after 12 months at 1000 mg/kg did not significantly reduce the incidence of hemangiosarcoma at 24 months. Evidence of carcinogenicity was not seen in two studies in Wistar rats following dietary administration of pregabalin for two years at doses (50, 150, or 450 mg/kg in males and 100, 300, or 900 mg/kg in females) that were associated with plasma exposures in males and females up to approximately 14 and 24 times, respectively, human exposure at the MRD. The clinical significance in humans of this finding in mice is unknown.

Mutagenesis
Pregabalin is not genotoxic based on results of a battery of in vitro and in vivo tests. Pregabalin was not mutagenic in bacteria or in mammalian cells in vitro, was not clastogenic in mammalian systems in vitro and in vivo, and did not induce unscheduled DNA synthesis in mouse or rat hepatocytes.

Dermatopathy

Skin lesions ranging from erythema to necrosis were seen in repeated-dose toxicology studies in both rats and monkeys. The etiology of these skin lesions is unknown. At the maximum recommended human dose (MRD) of 600 mg/day, there is a 2-fold safety margin for the dermatological lesions. The more severe dermatopathies involving necrosis were associated with pregabalin exposures (as expressed by plasma AUCs) of approximately 3 to 8 times those achieved in humans given the MRD. No increase in incidence of skin lesions was observed in clinical studies.

Ocular Lesions

Ocular lesions (characterized by retinal atrophy [including loss of photoreceptor cells] and/or corneal inflammation/mineralization) were observed in two lifetime carcinogenicity studies in Wistar rats. These findings were observed at plasma pregabalin exposures (AUC) ≥2 times those achieved in humans given the maximum recommended dose of 600 mg/day. A no-effect dose for ocular lesions was not established. Similar lesions were not observed in lifetime carcinogenicity studies in two strains of mice or in monkeys treated for 1 year. The clinical significance of this finding in rats is unknown.

Monitoring and Laboratory Tests

Routine therapeutic drug monitoring or clinical laboratory testing is not required for patients treated with LYRICA (see ADVERSE REACTIONS).

Adverse Reactions

Adverse Drug Reaction Overview

Clinical Trial Adverse Drug Reactions

Because clinical trials are conducted under very specific conditions, the adverse reaction rates observed in clinical trials may not reflect the rates observed in practice and should not be compared to the rates in clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates.

In all controlled and uncontrolled trials during the pre-marketing development of pregabalin, more than 8666 patients have received LYRICA (pregabalin), with 83% of exposure at dosages of 300 mg/day or above and 32% at dosages of 600 mg/day or higher. Approximately 4010 patients had at least 6 months of exposure, 2415 had at least 1 year of exposure, and 939 had at least 2 years of exposure to pregabalin. In controlled trials, 1831 patients with neuropathic pain received pregabalin. In all controlled and uncontrolled studies in fibromyalgia, 3446 patients have received pregabalin doses of 150-600 mg/day. A total of 969 patients had at least 6 months of exposure and 440 patients had at least 1 year exposure to pregabalin. Doses above 600 mg/day have not been studied.

In a controlled study of neuropathic pain due to spinal cord injury, 137 patients were randomized to receive placebo (N=67) or escalating doses (150-600 mg/day) of pregabalin, (N=70). The controlled study was followed by an open-label trial in which 103 patients received pregabalin (150-600 mg/day). The median duration of therapy across the double-blind and open-label studies for those subjects treated in the open-label extension was 608 days (range 14-1248). Sixty-nine (67%) subjects received at least 1 year of open-label pregabalin and 31 (30.1%) received at least 2 years of open-label pregabalin.

Most Common Adverse Events in All Pre-marketing Controlled Clinical Studies of Neuropathic Pain

The most commonly observed adverse events (≥ 5% and twice the rate of that seen in placebo) in pregabalin-treated patients in pre-marketing studies were: dizziness, somnolence, peripheral edema, and dry mouth. Adverse events were usually mild to moderate in intensity.

Discontinuation Due to Adverse Events in Pre-marketing Controlled Clinical Studies

In all pre-marketing controlled studies, the discontinuation rate due to adverse events was 14% for patients receiving pregabalin and 7% for patients receiving placebo. The most common reasons for discontinuation due to adverse events (≥2%) in the pregabalin treatment groups were dizziness and somnolence. Other adverse events that led to withdrawal more frequently in the pregabalin group than the placebo group were ataxia (1%), and asthenia, confusion, headache and nausea (<1% each).

In pre-marketing controlled neuropathic pain studies, the discontinuation rate due to adverse events was 11% for pregabalin and 5% for placebo. The most common reasons for discontinuation due to adverse events (≥2%) in the pregabalin treatment groups were dizziness and somnolence. Other adverse events that led to withdrawal more frequently in the pregabalin group than the placebo group were confusion (1%) and asthenia, peripheral edema and ataxia (<1% each).

Incidence of Adverse Events in Pre-marketing Controlled Clinical Studies of Neuropathic Pain

In summaries of adverse events, investigator's terms for individual adverse events have been grouped into a smaller number of standardized categories using the COSTART IV dictionary. The prescriber should be aware that the percentages in Table 1 through Table 8 cannot be used to predict the frequency of adverse events in the course of usual medical practice where patient characteristics and other factors may differ from those prevailing during clinical studies. Similarly, the cited frequencies cannot be directly compared with figures obtained from other clinical investigations involving different treatments, uses or investigators. An inspection of these frequencies, however, does provide the prescriber with one basis to estimate the relative contribution of drug and non-drug factors to the adverse event incidences in the population studied.

Adverse Events From Pre-marketing Controlled Clinical Studies of Neuropathic Pain

Diabetic Peripheral Neuropathy
Table 1 lists all adverse events, regardless of causality, occurring in ≥ 2% of patients with neuropathic pain associated with diabetic peripheral neuropathy receiving pregabalin for at least one of the pregabalin groups, and for which the incidence was greater than in the placebo group. A majority of pregabalin-treated patients in these studies had adverse events with a maximum intensity of mild or moderate. In these studies, 979 patients received pregabalin and 459 patients received placebo for up to 13 weeks.

Table 1. Incidence (%) of Treatment-Emergent Adverse Events in Placebo-Controlled Studies in Neuropathic Pain Associated with Diabetic Peripheral Neuropathy (Events in at Least 2% of Patients Receiving Pregabalin and More Frequent Than in Placebo- Treated Patients)

Body System
Preferred Term

Placebo
(N = 459)

%

Pregabalin(mg/day)

75

(N =77)

%

150

(N = 212)

%

300

(N = 321)

%

600

(N = 369)

%

Body as a whole

Infection

6.1

3.9

7.5

8.4

4.6

Asthenia

2.4

3.9

1.9

4.4

7.3

Pain

3.9

5.2

4.2

2.5

4.9

Accidental injury

2.8

5.2

2.4

2.2

5.7

Back pain

0.4

0.0

2.4

1.2

1.9

Chest pain

1.1

3.9

1.4

1.2

1.6

Face edema

0.4

0.0

0.9

0.9

2.2

Digestive system

     

Dry mouth

1.1

2.6

1.9

4.7

6.5

Constipation

1.5

0.0

2.4

3.7

6.0

Diarrhea

4.8

5.2

2.8

1.9

3.0

Flatulence

1.3

2.6

0

2.2

2.7

Vomiting

1.5

1.3

0.9

2.2

1.1

Hemic and lymphatic system

Ecchymosis

0.2

2.6

0.5

0.6

0.3

Metabolic and nutritional disorders

Peripheral edema

2.4

3.9

6.1

9.3

12.5

Weight gain

0.4

0.0

4.2

3.7

6.2

Edema

0.0

0.0

1.9

4.0

1.9

Hypoglycemia

1.1

1.3

3.3

1.6

1.1

Nervous system

Dizziness

4.6

7.8

9.0

23.1

29.0

Somnolence

2.6

3.9

6.1

13.1

16.3

Neuropathy

3.5

9.1

1.9

2.2

5.4

Ataxia

1.3

6.5

0.9

2.2

4.3

Vertigo

1.1

1.3

1.9

2.5

3.5

Confusion

0.7

0.0

1.4

2.2

3.3

Euphoria

0.0

0.0

0.5

3.4

1.6

Thinking abnormala

0.0

1.3

0.0

0.9

3.0

Abnormal gait

0.0

1.3

0.0

0.6

2.7

Reflexes decreased

1.7

3.9

0.5

1.2

1.4

Amnesia

0.2

2.6

0.9

0.0

2.2

Hypesthesia

0.7

2.6

0.0

0.0

0.8

Hyperalgesia

0.2

2.6

0.0

0.0

0.3

Respiratory system

Dyspnea

0.7

2.6

0.0

1.9

1.9

Skin and appendages

Pruritus

1.3

2.6

0.0

0.9

0.0

Special senses

Blurred visionb

1.5

2.6

1.4

2.8

5.7

Conjunctivitis

0.2

2.6

1.4

0.6

0.3

a Thinking abnormal primarily consists of events related to difficulty with concentration/attention but also includes events related to cognition and language problems and slow thinking.
b Investigator term; summary level term is amblyopia.

Discontinuation in Controlled Clinical Studies of Diabetic Peripheral Neuropathy

Approximately 9% of patients receiving pregabalin and 4% receiving placebo discontinued from controlled diabetic peripheral neuropathy studies due to adverse events. The adverse events most commonly leading to discontinuation are presented in Table 2.

Table 2. Adverse Events Most Frequently (≥2% of patients) Leading to Discontinuation in Placebo-Controlled Studies in Patients With Neuropathic Pain Associated with Diabetic Peripheral Neuropathy

Number (%) of Patients

COSTART

Preferred Term

Placebo
(N = 459)

Pregabalin (mg/day)

75

(N =77)

150

(N = 212)

300

(N = 321)

600

(N = 369)

Dizziness

2 (0.4)

0 (0.0)

3 (1.4)

6 (1.9)

21 (5.7)

Somnolence

0 (0.0)

0 (0.0)

0 (0.0)

5 (1.6)

15 (4.1)

Postherpetic Neuralgia

Table 3 lists all adverse events, regardless of causality, occurring in ≥ 2% of patients with neuropathic pain associated with postherpetic neuralgia receiving pregabalin for at least one of the pregabalin groups, and for which the incidence was greater than in the placebo group. A majority of pregabalin-treated patients in these studies had adverse events with a maximum intensity of mild or moderate. In these studies, 852 patients received pregabalin and 398 patients received placebo for up to 13 weeks.

Table 3. Incidence (%) of Treatment-Emergent Adverse Events in Placebo-Controlled Studies in Neuropathic Pain Associated with Postherpetic Neuralgia (Events in at Least 2% of Patients Receiving Pregabalin and More Frequent Than in Placebo-Treated Patients)

Body System
Preferred Term

Placebo
(N = 398)

%

Pregabalin (mg/day)

75

(N =84)

%

150

(N = 302)

%

300

(N = 312)

%

600

(N = 154)

%

Body as a whole

Infection

3.5

14.3

8.3

6.4

2.6

Headache

5.3

4.8

8.9

4.5

8.4

Pain

3.8

4.8

4.3

5.4

4.5

Asthenia

4.0

3.6

5.0

2.6

5.2

Accidental injury

1.5

3.6

2.6

3.2

5.2

Flu syndrome

1.3

1.2

1.7

2.2

1.3

Face edema

0.8

0.0

1.7

1.3

3.2

Malaise

1.0

2.4

0.3

0.6

0.0

Cardiovascular system

Vasodilatation

1.3

2.4

1.0

0.6

0.0

Digestive system

     

Dry mouth

2.8

7.1

7.0

6.1

14.9

Constipation

2.3

3.6

4.6

5.4

5.2

Diarrhea

4.0

2.4

4.3

3.5

4.5

Flatulence

1.0

2.4

1.3

1.6

3.2

Vomiting

0.8

1.2

0.7

2.9

2.6

Body System
Preferred Term

Placebo
(N = 398)

%

Pregabalin(mg/day)

75

(N =84)

%

150

(N = 302)

%

300

(N = 312)

%

600

(N = 154)

%

Metabolic and nutritional disorders

Peripheral edema

3.5

0.0

7.9

15.7

16.2

Weight gain

0.3

1.2

1.7

5.4

6.5

Edema

1.3

0.0

1.0

2.2

5.8

Hyperglycemia

0.8

2.4

0.3

0.0

0.0

Nervous system

Dizziness

9.3

10.7

17.9

31.4

37.0

Somnolence

5.3

8.3

12.3

17.9

24.7

Ataxia

0.5

1.2

2.0

5.4

9.1

Abnormal gait

0.5

0.0

2.0

3.8

7.8

Confusion

0.3

1.2

2.3

2.9

6.5

Thinking abnormala

1.5

0.0

1.7

1.3

5.8

Incoordination

0.0

2.4

1.7

1.3

2.6

Amnesia

0.0

0.0

1.0

1.3

3.9

Speech disorder

0.0

0.0

0.3

1.3

3.2

Insomnia

1.8

0.0

0.7

2.2

0.0

Euphoria

0.0

2.4

0.0

1.3

1.3

Nervousness

0.5

0.0

1.0

0.3

2.6

Tremor

1.5

1.2

0.0

1.0

2.6

Hallucinations

0.0

0.0

0.3

0.3

3.2

Hyperesthesia

0.3

2.4

0.3

0.0

1.3

Respiratory system

Bronchitis

0.8

0.0

1.3

1.0

2.6

Pharyngitis

0.8

0.0

2.6

0.6

0.6

Rhinitis

1.8

1.2

0.7

0.6

3.2

Skin and appendages

Rash

3.0

2.4

2.0

2.9

5.2

Special senses

Blurred visionb

2.5

1.2

5.0

5.1

9.1

Diplopia

0.0

0.0

1.7

1.9

3.9

Abnormal vision

0.3

0.0

1.0

1.6

5.2

Urogenital system

Urinary tract infection

1.5

0.0

2.3

1.6

3.2

a Thinking abnormal primarily consists of events related to difficulty with concentration/attention but also includes events related to cognition and language problems and slow thinking.
b Investigator term; summary level term is amblyopia.

Discontinuation in Controlled Clinical Studies of Postherpetic Neuralgia

Approximately 14% of patients receiving pregabalin and 7% receiving placebo discontinued from controlled postherpetic neuralgia studies due to adverse events. The adverse events most commonly leading to discontinuation are presented in Table 4.

Table 4. Adverse Events Most Frequently (≥2% of patients) Leading to Discontinuation in Placebo-Controlled Studies in Patients With Neuropathic Pain Associated with Postherpetic Neuralgia

Number (%) of Patients

COSTART

Preferred Term

Placebo
(N = 398)

Pregabalin (mg/day)

75

(N =84)

150

(N = 302)

300

(N = 312)

600

(N = 154)

Dizziness

3 (0.8)

0 (0.0)

11 (3.6)

12 (3.8)

12 (7.8)

Somnolence

1 (0.3)

0 (0.0)

6 (2.0)

12 (3.8)

10 (6.5)

Confusion

1 (0.3)

0 (0.0)

2 (0.7)

5 (1.6)

8 (5.2)

Peripheral edema

1 (0.3)

0 (0.0)

2 (0.7)

5 (1.6)

5 (3.2)

Ataxia

0 (0.0)

0 (0.0)

1 (0.3)

5 (1.6)

4 (2.6)

Abnormal gait

0 (0.0)

0 (0.0)

0 (0.0)

4 (1.3)

4 (2.6)

Hallucinations

0 (0.0)

0 (0.0)

0 (0.0)

1 (0.3)

4 (2.6)

Dry mouth

1 (0.3)

0 (0.0)

0 (0.0)

0 (0.0)

4 (2.6)

Incidence of Most Common Dose-Related Treatment-Emergent Adverse Events

Most common dose-related treatment-emergent adverse events are presented in Table 5 (diabetic peripheral neuropathy), Table 6 (postherpetic neuralgia), and Table 7 (fibromyalgia).

Table 5. Incidence (%) of Most Common Dose-Related Treatment-Emergent Adverse Events in Placebo-Controlled Studies in Neuropathic Pain Associated with Diabetic Peripheral Neuropathy

Adverse Event

Preferred Term

Placebo

Pregabalin (mg/day)

75

150

300

600

(N = 459)

(N =77)

(N = 212)

(N = 321)

(N = 369)

%

%

%

%

%

Dizziness

4.6

7.8

9.0

23.1

29.0

Somnolence

2.6

3.9

6.1

13.1

16.3

Peripheral edema

2.4

3.9

6.1

9.3

12.5

Asthenia

2.4

3.9

1.9

4.4

7.3

Dry mouth

1.1

2.6

1.9

4.7

6.5

Weight gain

0.4

0.0

4.2

3.7

6.2

Constipation

1.5

0.0

2.4

3.7

6.0

Blurred visiona

1.5

2.6

1.4

2.8

5.7

a Investigator term; summary level term is amblyopia.

Table 6. Incidence (%) of Most Common Dose-Related Treatment-Emergent Adverse Events in Placebo-Controlled Studies in Neuropathic Pain Associated with Postherpetic Neuralgia

Adverse Event

Preferred Term

Placebo

Pregabalin(mg/day)

75

150

300

600

(N = 398)

(N =84)

(N = 302)

(N = 312)

(N = 154)

%

%

%

%

%

Dizziness

9.3

10.7

17.9

31.4

37.0

Somnolence

5.3

8.3

12.3

17.9

24.7

Peripheral edema

3.5

0.0

7.9

15.7

16.2

Dry mouth

2.8

7.1

7.0

6.1

14.9

Blurred visiona

2.5

1.2

5.0

5.1

9.1

Ataxia

0.5

1.2

2.0

5.4

9.1

Weight gain

0.3

1.2

1.7

5.4

6.5

Abnormal gait

0.5

0.0

2.0

3.8

7.8

a Investigator term; summary level term is amblyopia.

Table 7. Incidence (%) of Most Common Dose-Related Treatment-Emergent Adverse Events in Placebo-Controlled Studies in Pain Associated with Fibromyalgia

System Organ Class and
Preferred Term
(MedDRA version 10.1)

Placebo
(N = 689)

%

Pregabalin(mg/day)

150

300

450

600

(N = 132)

(N = 685)

(N = 687)

(N = 564)

%

%

%

%

Dizziness

10.4

22.7

32.6

42.5

46.5

Somnolence

4.6

12.9

18.5

19.9

20.7

Weight increased

2.5

7.6

11.1

10.0

13.7

Peripheral edema

2.5

5.3

6.7

6.4

10.8

Dry mouth

1.7

6.8

6.7

9.2

9.4

Constipation

2.8

3.8

5.8

6.8

9.2

Fatigue

5.4

4.5

7.2

8.4

8.2

Balance disorder

0.1

1.5

3.2

4.9

6.9

Disturbance in attention

1.3

3.8

4.4

6.4

6.9

Increased appetite

1.3

3.8

3.4

4.5

5.5

Euphoria

0.9

1.5

4.1

4.8

5.1

Adverse Events From a Controlled Clinical Study in Neuropathic Pain Associated With Spinal Cord Injury

The most commonly observed treatment-related adverse events (≥ 5% and twice the rate of that seen in placebo) in pregabalin-treated patients were: somnolence, dizziness, asthenia, dry mouth, edema, myasthenia, constipation, thinking abnormal, amblyopia, and amnesia. Adverse events were usually mild to moderate in intensity.

Table 8 lists all adverse events, regardless of causality, occurring in ≥ 2% of patients receiving pregabalin and for which the incidence was greater than in the placebo group. A majority of pregabalin-treated patients had adverse events with a maximum intensity of mild or moderate. In this study, 70 patients received pregabalin and 67 patients received placebo for up to 12 weeks.

Table 8. Incidence (%) of Treatment-Emergent Adverse Events in a Placebo-Controlled Study in Neuropathic Pain Associated With Spinal Cord Injury (Events in at Least 2% of Patients Receiving Pregabalin and More Frequent Than in Placebo-Treated Patients)

Body System
Preferred Term

Placebo

N = 67

%

Pregabalin
(150 - 600 mg/day)

N = 70

%

Body as a whole

  

Asthenia

6.0

15.7

Infection

6.0

8.6

Abdomen enlarged

0.0

4.3

Pain

1.5

4.3

Back pain

1.5

2.9

Cellulitis

0.0

2.9

Flu syndrome

1.5

2.9

Neck pain

1.5

2.9

Cardiovascular system

  

Hypotension

0.0

2.9

Digestive system

  

Dry mouth

3.0

15.7

Constipation

6.0

12.9

Gastroenteritis

0.0

2.9

Increased appetite

0.0

2.9

Metabolic and nutritional disorders

  

Edema

0.0

12.9

Peripheral edema

6.0

10.0

Weight gain

0.0

4.3

Musculoskeletal system

  

Myasthenia

4.5

8.6

Joint disorder

0.0

2.9

Nervous system

  

Somnolence

9.0

41.4

Dizziness

9.0

24.3

Amnesia

3.0

10.0

Thinking abnormala

1.5

8.6

Paresthesia

1.5

5.7

Euphoria

0.0

4.3

Speech disorder

1.5

4.3

Twitching

0.0

4.3

Withdrawal syndrome

0.0

4.3

Skin and appendages

  

Skin ulcer

1.5

4.3

Alopecia

0.0

2.9

Vesiculobullous rash

0.0

2.9

Special senses

  

Blurred visionb

3.0

8.6

Diplopia

1.5

2.9

Tinnitus

0.0

2.9

Urogenital system

  

Urinary incontinence

3.0

5.7

a Thinking abnormal primarily consists of events related to difficulty with concentration/attention but also includes events related to cognition and language problems and slow thinking.

b Investigator term; summary level term is amblyopia.

Discontinuation in a Controlled Clinical Study in Neuropathic Pain Associated With Spinal Cord Injury

Approximately 21% of patients receiving pregabalin and 13% receiving placebo discontinued due to adverse events. The adverse events most commonly leading to discontinuation are presented in Table 9.

Table 9. Adverse Events Most Frequently (≥2% of patients) Leading to Discontinuation in a Placebo-Controlled Study in Patients With Neuropathic Pain Associated with Spinal Cord Injury

Number(%) of Patients

COSTART

Preferred Term

Placebo
(N = 67)

Pregabalin
(N = 70)

150 – 600 mg/day

Somnolence

0 (0.0)

4 (5.7)

Edema

0 (0.0)

4 (5.7)

Asthenia

0 (0.0)

3 (4.3)

Overall, the most frequent treatment-related adverse events in the open-label study were related to the nervous system and included: somnolence (18.4%), dizziness (16.5%), and insomnia (10.7%). Other frequent treatment-related adverse events included: asthenia (12.6%), nausea (11.7%), and constipation (10.7%).

Most Common Adverse Events in Controlled Clinical Studies in Fibromyalgia
The most commonly observed treatment-related adverse events (≥ 5% and twice the rate of that seen in placebo) in pregabalin-treated patients were: dizziness (37.5), somnolence (18.6), weight gain (10.6), dry mouth (7.9), blurred vision (6.7), peripheral edema (6.1), constipation (5.8), and disturbance in attention (5.3). Adverse events were usually mild to moderate in intensity.

Adverse Events from Controlled Clinical Studies in Fibromyalgia
Table 10 lists all adverse events occurring in ≥2% of patients receiving pregabalin and for which the incidence was greater than in the placebo group. A majority of pregabalin-treated patients in these studies had adverse events with mild or moderate intensity. There was a dose-related increase in the incidence of adverse events (see Table 7). Severe adverse events occurred at roughly the same rate in low versus high doses of pregabalin.

Table 10. Incidence (%) of Treatment-Emergent Adverse Events in Controlled Fibromyalgia Studies (in at Least 2% of Pregabalin-Treated Patients and More Frequent Than in Placebo-Treated Patients)

System Organ Class and
Preferred Term
(MedDRA version 10.1)

 

Pregabalin (mg/day)

Placebo
(N = 689)

%

150

(N = 132)

%

300

(N = 685)

%

450

(N = 687)

%

600

(N = 564)

%

Ear and labyrinth disorders

Vertigo

0.9

1.5

3.1

3.2

3.5

Eye disorders

Blurred visiona

1.0

8.3

5.8

6.4

10.1

Gastrointestinal disorders

Dry mouth

1.7

6.8

6.7

9.2

9.4

Constipation

2.8

3.8

5.8

6.8

9.2

Abdominal distention

1.5

2.3

2.2

1.9

2.0

Flatulence

1.0

0.8

0.9

2.0

2.3

General disordersand administration site conditions

Fatigue

5.4

4.5

7.2

8.4

8.2

Peripheral edema

2.5

5.3

6.7

6.4

10.8

Feeling abnormal

0.3

0.8

1.9

1.9

2.0

Feeling drunk

0

0.8

2.3

1.5

2.1

Infections and infestations

Sinusitis

3.0

3.8

3.6

5.2

4.1

Investigations

Weight increased

2.5

7.6

11.1

10.9

13.7

Metabolism and nutritional disorders

Increased appetite

1.3

3.8

3.4

4.5

5.5

Fluid retention

0.7

1.5

2.2

2.0

2.0

Musculoskeletal and connective tissue disorders

Arthralgia

2.5

3.8

3.6

3.2

4.6

Muscle spasm

1.9

2.3

3.4

3.3

3.2

Nervous system disorders

Dizziness

10.4

22.7

32.6

42.5

46.5

Somnolence

4.6

12.9

18.5

19.9

20.7

Disturbance in attention

1.3

3.8

4.4

6.4

6.9

Balance Disorder

0.1

1.5

3.2

4.9

6.9

Memory Impairment

0.6

0.8

2.6

3.5

3.5

Hypoesthesia

0.6

1.5

2.0

2.8

2.3

Temor

0.6

0

0.6

2.9

3.0

Lethargy

0.4

2.3

1.3

0.7

1.4

Psychiatric disorders

Euphoria

0.9

1.5

4.1

4.8

5.1

Anxiety

0.9

1.5

1.9

2.5

1.8

Confusion

0.1

0

2.0

1.9

2.7

aInvestigator term; summary level term is amblyopia.

Discontinuation Due to Adverse Events in Controlled Clinical Studies in Fibromyalgia

Approximately 20% of patients receiving pregabalin and 11% receiving placebo discontinued due to adverse events. The adverse events most commonly leading to discontinuation were dizziness (6.1%) and somnolence (3.3%) as presented in Table 11. Other events leading to discontinuation in clinical trials of fibromyalgia included weight gain (1.1%), vision blurred (0.8%) and peripheral edema (0.6%). There was a dose-dependent increase in rate of discontinuation due to adverse events.

Table 11. Adverse Events Most Frequently (≥2% of patients) Leading to Discontinuation in Placebo-Controlled Studies in Patients With Pain Associated with Fibromyalgia

Number (%) of Patients

System Organ Class and
Preferred Term
(MedDRA version 10.1)

Placebo
(N=689)

Pregabalin (mg/day)

150

(N =132)

300

(N = 675)

450

(N = 687)

600

(N = 564)

Dizziness

0.4%

1.5%

4.1%

6.6%

9.2%

Somnolence

0.1%

0.8%

2.9%

3.2%

4.6%

Adverse Events Following Abrupt or Rapid Discontinuation

Following abrupt or rapid discontinuation of pregabalin, some patients reported symptoms including insomnia, nausea, headache, anxiety, hyperhidrosis, and diarrhea. Pregabalin should be tapered gradually over a minimum of one week rather than discontinued abruptly [see WARNINGS AND PRECAUTIONS, Abrupt or Rapid Discontinuation].

Other Events Observed During the Premarketing Evaluation of LYRICA
Following is a list of treatment-emergent adverse events reported during premarketing assessment of LYRICA in clinical trials (over 8600 adult subjects) except those already listed in the previous tables or elsewhere in labeling. In the tabulations that follow, a COSTART-based dictionary of terminology has been used to classify reported adverse events. The frequencies presented, therefore, represent the proportion of the over 8600 adult individuals exposed to multiple doses of LYRICA who experienced an event of the type cited on at least 1 occasion while receiving LYRICA. It is important to emphasize that although the events reported occurred during treatment with LYRICA, they were not necessarily caused by it.

Less Common Clinical Trial Adverse Drug Reactions (<2%)

Events are further categorized by body system and listed in order of decreasing frequency according to the following definitions: frequent adverse events are those occurring on 1 or more occasions in at least 1/100 patients; infrequent adverse events are those occurring in 1/100 to 1/1000 patients; rare events are those occurring in fewer than 1/1000 patients.

Body System

Adverse Events

Body as a whole

 

Frequent

Flu syndrome, back pain, allergic reaction, fever, generalized edema

Infrequent

Neck pain, neoplasm, cellulitis, cyst, chills, malaise, overdose, moniliasis, hernia, viral infection, photosensitivity reaction, pelvic pain, abdomen enlarged, abscess, neck rigidity, lab test abnormal, drug level increased, carcinoma, sepsis, suicide attempt, reaction unevaluable

Rare

Infection fungal, unexpected benefit, chills and fever, body odor, drug level decreased, halitosis, hangover effect, injection site reaction, hormone level altered, hypothermia, infection bacterial, injection site hemorrhage, intentional overdose, mucous membrane disorder, accidental overdose, adenoma, anaphylactoid reaction, ascites, chest pain substernal, death, sarcoidosis, sudden death, immune system disorder, increased drug effect, injection site pain, Lupus Erythematosus syndrome, medication error, sarcoma, shock, tolerance decreased

Cardiovascular

 

Frequent

Hypertension, vasodilatation

Infrequent

Palpitation, migraine, tachycardia, peripheral vascular disorder, electrocardiogram abnormal, cardiovascular disorder, angina pectoris, congestive heart failure, hemorrhage, myocardial infarct, hypotension, postural hypotension, ventricular extrasystoles, atrial fibrillation, coronary artery disorder, bradycardia, cerebrovascular accident, arrhythmia, cerebral ischemia, vascular disorder, sinus bradycardia, myocardial ischemia, bundle branch block, AV block first degree, arteriosclerosis, deep thrombophlebitis, phlebitis, arterial anomaly, heart failure, pulmonary embolus, retinal vascular disorder, varicose vein

Rare

Heart arrest, vascular anomaly, occlusion, supraventricular tachycardia, atrial arrhythmia,  atrial flutter, cerebral infarct, coronary occlusion, thrombophlebitis, thrombosis, cardiomegaly, extrasystoles, pallor, AV block, AV block second degree, cardiomyopathy, peripheral gangrene, QT interval prolonged, retinal artery occlusion, supraventricular extrasystoles, cerebral hemorrhage, digitalis intoxication, ventricular arrhythmia, aortic stenosis, bigeminy, cerebrovascular disorder, left heart failure, ventricular tachycardia, AV block complete, carotid occlusion, carotid thrombosis, cor pulmonale, embolus lower extremity, endocarditis, heart block, increased capillary fragility, intracranial aneurysm, nodal tachycardia, QT interval shortened, retinal vein thrombosis, ST elevated, T inverted, vascular headache, vasculitis

Digestive system

Frequent

Nausea, diarrhea, anorexia, gastrointestinal disorder

Infrequent

Gastroenteritis, tooth disorder, periodontal abscess, colitis, gastritis, liver function tests abnormal, increased salivation, thirst, nausea and vomiting, rectal disorder, gingivitis, dysphagia, stomatitis, mouth ulceration, cholelithiasis, rectal hemorrhage, gastrointestinal hemorrhage, glossitis, tooth caries, abnormal stools, cholecystitis, melena, oral moniliasis, esophagitis, tongue disorder, cheilitis, tongue edema

Rare

Eructation, pancreatitis, stomach ulcer, ulcerative stomatitis, esophageal stenosis, fecal incontinence, gum hemorrhage, intestinal obstruction, enteritis, peptic ulcer, enterocolitis, gum hyperplasia, hepatomegaly, liver fatty deposit, tenesmus, biliary pain, fecal impaction, jaundice, periodontitis, ulcerative colitis, aphthous stomatitis, cholestatic jaundice, gastrointestinal carcinoma, hemorrhagic gastritis, hepatitis, liver tenderness, nausea, vomiting and diarrhea, salivary gland enlargement, stomach atony, bloody diarrhea, cardiospasm, duodenal ulcer, gamma glutamyl transpeptidase increased, hematemesis, hepatoma, intestinal perforation, intestinal stenosis, intestinal ulcer, leukoplakia of mouth, necrotizing pancreatitis, pancreas disorder, pseudomembranous colitis, sialadenitis, stomach ulcer hemorrhage, tongue discoloration

Body System

Adverse Events

Endocrine system

Infrequent

Diabetes mellitus, hypothyroidism

Rare

Goiter, prolactin increased, thyroid disorder, gonadotropic follicle stim hormone increase, hyperthyroidism, thyroiditis, adrenal insufficiency, parathyroid disorder, thyroid carcinoma, thyroid neoplasia, virilism

Hemic and lymphatic

Infrequent

Anemia,  leukopenia,  thrombocytopenia,  lymphadenopathy,  hypochromic  anemia,  leukocytosis, eosinophilia

Rare

Lymphocytosis, petechia, iron deficiency anemia, cyanosis, lymphedema, polycythemia, lymphoma like reaction, megaloblastic anemia, splenomegaly, purpura, thrombocythemia, thrombocytopenic purpura, chronic leukemia, coagulation disorder, erythrocytes abnormal, leukemoid reaction, lymphangitis, macrocytic anemia, neutropenia, pancytopenia, prothrombin decreased, rupture of spleen, sedimentation rate increased

Metabolic and nutritional

Infrequent

Hyperglycemia, SGPT increased, hypoglycemia, hypokalemia, hypercholesteremia, SGOT increased, weight loss, hyperlipemia, amylase increased, hyperuricemia, alkaline phosphatase increased, creatinine increased, hyponatremia, gout, dehydration, BUN increased, healing abnormal

Rare

Hypercalcemia, hyperkalemia, hypocalcemia, bilirubinemia, alcohol intolerance, hypoglycemic reaction, ketosis, calcium disorder, hypochloremia, hypomagnesemia, hypoproteinemia, NPN increased, uremia, acidosis, avitaminosis, enzymatic abnormality, gamma globulins increased, hypernatremia, hypophosphatemia, lactic acidosis, obesity

Musculoskeletal system

Frequent

Arthralgia, myalgia, arthritis, leg cramps, myasthenia

Infrequent

Tendon  disorder,  arthrosis,  joint  disorder,  bone  disorder,  tenosynovitis,  bursitis,  tendinous contracture, osteoporosis, tendon rupture, bone pain

Rare

Rheumatoid arthritis, osteomyelitis, rhabdomyolysis, myopathy, muscle atrophy, myositis, pyogenic arthritis, bone neoplasm, musculoskeletal congenital anomaly, pathological fracture

Nervous system

Frequent

Insomnia, anxiety, libido decreased, depersonalization, hypertonia, neuropathy

Infrequent

Reflexes decreased, sleep disorder, abnormal dreams, hostility, hallucinations, hyperkinesia, personality disorder, dysarthria, hyperesthesia, hypokinesia, circumoral paresthesia, libido increased, neuralgia, vestibular disorder, aphasia, movement disorder, hyperalgesia, apathy, hypotonia, convulsion, facial paralysis, psychosis

Rare

Drug dependence, neuritis, paranoid reaction, CNS depression, CNS neoplasia, manic reaction, neurosis, extrapyramidal syndrome, meningitis, hemiplegia, reflexes increased, akathisia, delirium, paralysis, withdrawal syndrome, brain edema, CNS stimulation, dyskinesia, encephalopathy, foot drop, grand mal convulsion, hypalgesia, peripheral neuritis, psychotic depression, addiction, arachnoiditis, cerebellar syndrome, cogwheel rigidity, dementia, dystonia, Guillain-Barre syndrome, intracranial hemorrhage, multiple sclerosis, myelitis, schizophrenic reaction, subarachnoid hemorrhage, torticollis

Respiratory system

Frequent

Sinusitis, rhinitis, dyspnea, cough increased, pneumonia, lung disorder

Infrequent

Asthma, epistaxis, laryngitis, voice alteration, respiratory disorder, sputum increased

Body System

Adverse Events

  

Rare

Apnea, emphysema, aspiration pneumonia, hyperventilation,  lung edema, pleural  disorder, atelectasis, hemoptysis, hiccup, hypoxia, laryngismus, lung fibrosis, pleural effusion, lung function decreased, pulmonary hypertension, yawn, bronchiectasis, bronchiolitis, carcinoma of lung, hypoventilation, laryngeal neoplasia, nasal septum disorder, pneumothorax

Skin and appendages

Infrequent

Pruritus, sweating, skin disorder, acne, dry skin, alopecia, skin ulcer, herpes simplex, urticaria, nail disorder, eczema, herpes zoster, skin benign neoplasm, fungal dermatitis, maculopapular rash, vesiculobullous rash, skin carcinoma, furunculosis, skin discoloration, skin hypertrophy, psoriasis, seborrhea, hirsutism

Rare

Skin nodule, angioedema, cutaneous moniliasis, skin atrophy, exfoliative dermatitis, pustular rash, ichthyosis, skin melanoma, subcutaneous nodule, sweating decreased, hair disorder, lichenoid dermatitis, melanosis, miliaria, purpuric rash, skin necrosis, Stevens Johnson Syndrome

Special sense

Frequent

Eye disorder, conjunctivitis, otitis media

Infrequent

Retinal disorder, tinnitus, eye pain, cataract specified, dry eyes, taste perversion, ear pain, lacrimation disorder, ear disorder, deafness, eye hemorrhage, photophobia, glaucoma, vitreous disorder, corneal lesion, otitis externa, refraction disorder, blepharitis, retinal edema, taste loss, abnormality of accommodation

Rare

Hyperacusis, keratitis, mydriasis, parosmia, ptosis, retinal hemorrhage, color blindness, retinal depigmentation, retinal  detachment,  corneal opacity,  corneal  ulcer,  iritis, night blindness,  optic atrophy, retinal degeneration, cataract NOS, scleritis, strabismus, anisocoria, blindness, exophthalmos, keratoconjunctivitis, ophthalmoplegia, papilledema

Urogenital system

Frequent

Anorgasmia

Infrequent

Urinary frequency, urinary incontinence, cystitis, abnormal ejaculation, urination impaired, dysuria, metrorrhagia, hematuria, vaginal moniliasis, prostatic disorder, vaginitis, dysmenorrhea, urinary urgency, kidney calculus, breast pain, menstrual disorder, amenorrhea, menorrhagia, kidney function abnormal, nephritis, urine abnormality, vaginal hemorrhage, urinary retention, urinary tract disorder, leukorrhea, breast neoplasm, menopause, oliguria, polyuria, albuminuria, pyuria,

Rare

Breast carcinoma, penis disorder, papanicolau smear suspicious, fibrocystic breast, prostatic carcinoma, uterine fibroids enlarged, acute kidney failure, creatinine clearance decreased, nephrosis, nocturia, polycystic kidney, bladder carcinoma, breast enlargement, cervicitis,  cervix  disorder, female lactation, glycosuria, gynecomastia, hypomenorrhea, kidney pain, mastitis, pyelonephritis, kidney failure, breast abscess, epididymitis, orchitis, prostate neoplasia, prostatic specific antigen increase, salpingitis, urogenital disorder, urolithiasis, uterine disorder, vulvovaginal disorder, balanitis, bladder calculus, calcium crystalluria, cervix neoplasm, dyspareunia, endometrial carcinoma, endometrial disorder, glomerulitis, hydronephrosis, ovarian cancer, unintended pregnancy, urethral pain, urethritis, urogenital anomaly, urogenital neoplasia, uterine hemorrhage

Comparison of Gender and Race

The overall adverse event profile of pregabalin was similar between women and men. There are insufficient data to support a statement regarding the distribution of adverse experience reports by race.

Peripheral Edema
Incidence of peripheral edema in pre-marketing controlled peripheral neuropathic pain studies was 10.4% in the pregabalin group compared with 2.9% in the placebo group. The incidence in the controlled fibromyalgia studies was 7.6% in the pregabalin group compared with 2.5% in the placebo group. In clinical trials, these events of peripheral edema were dose-related, mostly mild to moderate in intensity and rarely led to withdrawal. Peripheral edema was not associated with cardiovascular complications such as hypertension or congestive heart failure and there was no evidence of hemodilution or changes in any laboratory parameters indicative of underlying organ dysfunction (see WARNINGS AND PRECAUTIONS, Peripheral Edema).

Weight Gain
In the pre-marketing controlled peripheral neuropathic pain studies, patients on pregabalin had a higher incidence (5.9%) of weight gain as defined by a ≥7% increase from baseline weight as compared with the placebo group (1.6%). The mean change in the pregabalin group was an increase of 1.5 kg compared with 0.2 kg in the placebo group; few patients (0.1%) withdrew due to weight gain.

The incidence in the controlled fibromyalgia studies was 11.5% in the pregabalin group compared with 2.5% in the placebo group; approximately 1% of pregabalin-treated patients withdrew due to weight gain.

This weight gain was dose-related, and not associated with clinically important changes in blood pressure or cardiovascular adverse events. There was no relationship between baseline body mass index and the incidence of ≥7% weight gain in the controlled trials.

Based on the results of a controlled study of reproductive function in healthy male volunteers, the ≥ 7% weight gain on pregabalin appeared to be reversible. In this study, there were no reports of peripheral edema (see WARNINGS AND PRECAUTIONS, Weight Gain).

Abnormal Hematologic And Clinical Chemistry Findings

In all pre-marketing controlled trials, 1.0% of patients on pregabalin and 0.5% of placebo patients had an increase in creatine kinase of ≥ 3X upper limit of normal. Renal dysfunction was generally not associated with the elevated creatine kinase in these patients. Mean changes in creatine kinase ranged from 9.6 to 26.3 U/L for pregabalin-treated patients and 4.8 U/L for the placebo patients (see DOSAGE AND ADMINISTRATION, Patients With Renal Impairment). Routine therapeutic drug monitoring or clinical laboratory testing is not required for patients treated with LYRICA (see WARNINGS AND PRECAUTIONS, Creatinine Kinase Elevations).

Post-Marketing Adverse Drug Reactions

Since the first global approval of LYRICA on 06 July 2004 through 31 March 2012, there has been an estimated 15,951,859 million patient-years of exposure to LYRICA. Table 12 is based on post-market spontaneous adverse event reports. The percentages shown are calculated by dividing the number of adverse events reported to the company by the estimated number of patient years exposed to LYRICA. Because these adverse reactions are reported spontaneously from a population of uncertain size, it is not possible to reliably estimate their frequency. Furthermore, a causal relationship between LYRICA and the emergence of these events has not been clearly established.

Table 12. Post-market Spontaneous Adverse Event Reports

Adverse Event

Frequency

 

Common

≥ 1%

Uncommon

< 1% and

≥ 0.1%

Rare

< 0.1% and

≥ 0.01%

Very rare

< 0.01%

Cardiovascular

    

congestive heart failurea

   

X

Eye disordersb

    

diplopia

   

X

vision blurred

   

X

visual disturbance

   

X

vision loss

   

X

Psychiatric disorders

    

aggression

   

X

confusional state

   

X

depression

   

X

euphoric mood

   

X

insomnia

   

X

psychotic disorderc

   

X

Gastrointestinal disorders

    

diarrhea

   

X

dry mouth

   

X

nausea

   

X

vomiting

   

X

intestinal obstructiond

   

X

paralytic ileusd

   

X

General disorders and administration site conditions

    

fatigue

   

X

feeling abnormal

   

X

pain

   

X

Immune system disorders

    

angioedemae

   

X

hypersensitivity f

   

X

Nervous system disorders

    

ataxia

   

X

coordination abnormal

   

X

dizzinessg

   

X

dysarthria

   

X

headache

   

X

memory impairment

   

X

paresthesia

   

X

somnolenceg

   

X

speech disorder

   

X

tremor

   

X

Adverse Event

Frequency

 

Common

≥ 1%

Uncommon

< 1% and

≥ 0.1%

Rare

< 0.1% and

≥ 0.01%

Very rare

< 0.01%

coma

   

X

loss of consciousness

   

X

mental impairment

   

X

Renal and urinary disorders

    

urinary retention

   

X

Respiratory, thoracic and mediastinal disorders

    

dyspnea

   

X

pulmonary edema

   

X

Skin and subcutaneous tissue disorders

    

hyperhidrosis

   

X

pruritus

   

X

a
These reactions are mostly seen in elderly cardiovascular compromised patients during pregabalin treatment for a neuropathic pain indication (see WARNINGS AND PRECAUTIONS, Congestive Heart Failure)
b
There have also been rare reports of accommodation disorder, eyelid edema and eye redness (see WARNINGS AND PRECAUTIONS, Opthalmological Effects)
c
There have been rare reports of psychotic disorders in patients receiving pregabalin
d
See below and WARNINGS AND PRECAUTIONS, Gastrointestinal
e
see WARNINGS AND PRECAUTIONS, Angioedema
f
see WARNINGS AND PRECAUTIONS, Hypersensitivity
g
see WARNINGS AND PRECAUTIONS, Dizziness and Somnolence

Gastrointestinal: There have been post-marketing events related to reduced lower gastrointestinal tract function (eg. intestinal obstruction, paralytic ileus, and constipation) primarily reported when LYRICA was given in combination with other medications that have the potential to produce constipation, such as opioid analgesics (see WARNINGS AND PRECAUTIONS, Gastrointestinal).

Urinary and Renal Disorder: renal failure. There have been rare post-marketing reports of patients, with or without previous history, experiencing renal failure while receiving pregabalin alone or in combination with other medications. Discontinuation of pregabalin showed reversibility of this event in some cases. Caution is advised when prescribing pregabalin to the elderly or those with impaired renal function (see Special Populations, Renal; WARNINGS and PRECAUTIONS, Renal Failure, and DOSAGE AND ADMINISTRATION).

Cardiovascular: congestive heart failure. These reactions are mostly seen in elderly cardiovascular compromised patients during pregabalin treatment for a neuropathic pain indication (see WARNINGS AND PRECAUTIONS, Congestive Heart Failure).

Respiratory, Thoracic and Mediastinal Disorder: pulmonary edema. There have been post- marketing reports of pulmonary edema in patients receiving pregabalin. Although this adverse reaction has mostly been observed in elderly patients with predisposing factors, some cases have occurred in patients with no known previous history or predisposing conditions.

Eye disorders: diplopia, vision blurred, visual disturbance and vision loss. There have also been rare reports of accommodation disorder, eyelid edema and eye redness (see WARNINGS AND PRECAUTIONS, Opthalmological Effects).

Encephalopathy: There have been serious post-marketing reports of encephalopathy, mostly in patients with underlying conditions that may precipitate encephalopathy. Some cases were reported in patients with a history of kidney or liver disease. Since there have been rare reports of renal failure with LYRICA, specific caution should be exercised when prescribing LYRICA to the elderly with age-related compromised renal function and patients with kidney disease or risk factors for renal failure (see WARNINGS AND PRECAUTIONS, Renal Failure and WARNINGS AND PRECAUTIONS, Encephalopathy).

Convulsions: convulsions, including status epilepticus and grand mal convulsions, have been reported in non-epileptic patients during treatment with LYRICA or following abrupt discontinuation (see WARNINGS AND PRECAUTIONS, Abrupt Discontinuation).

Suicidal Behaviour and Ideation: There have been post-marketing reports of suicide-related events, including completed suicide, suicide attempt, and suicidal ideation in patients treated with LYRICA for a variety of indications such as neuropathic pain, fibromyalgia, etc. In some of these reports, underlying psychiatric disorders may have contributed to the event. The mechanism of this risk is not known. Patients should be monitored for signs of suicidal ideation and behaviours and appropriate treatment should be considered. Patients should be encouraged to report any distressing thoughts or feelings at anytime to their healthcare professional (see WARNINGS AND PRECAUTIONS, Suicidal Behaviour and Ideation).

Serious Skin Reactions

There have been very rare post-marketing reports of serious cutaneous reactions, including Stevens-Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN), dermatitis exfoliative, bullous skin reactions, and erythema multiforme in patients treated with LYRICA (see WARNINGS AND PRECATIONS). Post-market reporting rate is generally accepted to be an underestimate due to under-reporting. Most of the reports were in patients taking concomitant medications also associated with the potential development of these serious skin reactions. Therefore, in most cases, causality in relation to LYRICA could not be clearly established. Patients should be advised that if they experience a skin rash, they should discontinue LYRICA treatment and contact their physician for assessment and advice.

Drug Abuse and Dependence/Liability

In a study of recreational users (N=15) of sedative/hypnotic drugs, including alcohol, a single dose of LYRICA 450 mg received subjective ratings of “good drug effect”, “high”, and “liking” to a degree that was similar to a single dose of diazepam 30 mg. In controlled clinical studies in over 5500 patients, 4% of LYRICA-treated patients and 1% of placebo-treated patients overall reported euphoria as an adverse event. However, in clinical trials of diabetic peripheral neuropathy, euphoria was reported as an adverse event by 1.8% of LYRICA-treated patients and 0 % of placebo-treated patients, and in clinical trials of postherpetic neuralgia, euphoria was reported as an adverse event by 0.9% of LYRICA-treated patients and 0% of placebo-treated patients. In clinical studies, following abrupt or rapid discontinuation of pregabalin, some patients reported symptoms including insomnia, nausea, headache, anxiety, hyperhidrosis, or diarrhea suggestive of physical dependence [see WARNINGS AND PRECAUTIONS, Abrupt or Rapid Discontinuation].

Pregabalin is not known to be active at receptor sites associated with drugs of abuse. As with any CNS active drug, physicians should carefully evaluate patients for history of drug abuse and observe them for signs of LYRICA misuse or abuse (eg, development of tolerance, dose escalation, drug-seeking behaviour).

Drug Interactions

Overview

Since pregabalin is predominately excreted unchanged in the urine, undergoes negligible metabolism in humans (≤ 2% of a dose recovered in urine as metabolites), does not inhibit drug metabolism in vitro, and is not bound to plasma proteins, LYRICA (pregabalin) is unlikely to produce, or be subject to, pharmacokinetic interactions.

Pharmacokinetic

In Vitro Studies: In vitro drug metabolism studies revealed that pregabalin at concentrations which were, in general, 10-fold greater than observed in Phase 2/3 clinical trials, does not inhibit human CYP1A2, CYP2A6, CYP2C9, CYP2C19, CYP2D6, CYP2E1, and CYP3A4 enzyme systems.

In Vivo Studies: The drug interaction data described in this section were obtained from studies involving healthy adults, patients with epilepsy, and patients with chronic pain disorders.

Carbamazepine, valproic acid, lamotrigine, phenytoin, phenobarbital, and topiramate: In vitro and in vivo studies showed that LYRICA is unlikely to be involved in significant pharmacokinetic drug interactions. Specifically, there are no clinically significant pharmacokinetic interactions between pregabalin and the following antiepileptic drugs: carbamazepine, valproic acid, lamotrigine, phenytoin, phenobarbital, and topiramate. Important pharmacokinetic interactions would also not be expected to occur between pregabalin and commonly used antiepileptic drugs.

Tiagabine: The results of a population pharmacokinetic analysis indicated that in patients with partial seizures tiagabine had no clinically significant effect on pregabalin clearance.

Gabapentin: The pharmacokinetics of pregabalin and gabapentin were investigated in 12 healthy subjects following concomitant single dose administration of 100 mg pregabalin and 300 mg gabapentin, and in 18 healthy subjects following concomitant multiple dose administration of 200 mg pregabalin q8h and 400 mg gabapentin q8h. Gabapentin pharmacokinetics following single and multiple dose administration were unaltered by pregabalin coadministration. The rate of pregabalin absorption was reduced by approximately 26% (single dose administration) and 18% (multiple dose administration) based on lower Cmax values; however, the extent of pregabalin absorption was unaffected by gabapentin coadministration.

Oral Contraceptives: Pregabalin coadministration (200 mg TID) had no effect on the steady state pharmacokinetics of norethindrone and ethinyl estradiol (1 mg/35 µg, respectively) in healthy subjects.

Lorazepam: Multiple dose administration of pregabalin (300 mg BID) in healthy subjects had no effect on the rate and extent of lorazepam single dose pharmacokinetics and single dose administration of lorazepam (1 mg) had no clinically significant effect on the steady state pharmacokinetics of pregabalin.

Oxycodone: Multiple dose administration of pregabalin (300 mg BID) in healthy subjects had no effect on the rate and extent of oxycodone single dose pharmacokinetics. Single dose administration of oxycodone (10 mg) had no clinically significant effect on the steady state pharmacokinetics of pregabalin.

Ethanol: Multiple dose administration of pregabalin (300 mg BID) in healthy subjects had no effect on the rate and extent of ethanol single dose pharmacokinetics and single dose administration of ethanol (0.7 g/kg) had no clinically significant effect on the steady state pharmacokinetics of pregabalin.

Diuretics, Oral Hypoglycemics, and Insulin: A population pharmacokinetic analysis in patients with chronic pain showed no clinically significant effect on pregabalin clearance with the concomitant use of diuretics, oral hypoglycemics, and insulin.

Pharmacodynamic

Oxycodone, lorazepam, ethanol: Multiple oral doses of pregabalin co-administered with oxycodone, lorazepam, or ethanol did not result in clinically important effects on respiration. Pregabalin may potentiate the effects of ethanol and lorazepam. Pregabalin appears to be additive in the impairment of cognitive and gross motor function caused by oxycodone.

In post-marketing experience, there are reports of respiratory failure and coma in patients taking pregabalin alone or in combination with other CNS depressants.

Thiazolidinedione Antidiabetic Agents: Higher frequencies of weight gain and peripheral edema were observed in patients taking both LYRICA and a thiazolidinedione antidiabetic agent compared to patients taking either drug alone. The majority of patients using thiazolidinedione antidiabetic agents in the overall safety database were participants in studies of pain associated with diabetic peripheral neuropathy.

As the thiazolidinedione class of antidiabetic drugs or LYRICA can cause weight gain and/or fluid retention alone or together, possibly exacerbating or leading to heart failure, caution should be exercised when co-administering LYRICA and these agents (see WARNINGS AND PRECAUTIONS, Peripheral Edema).

Drug-Food Interactions

The rate of pregabalin absorption is decreased when given with food resulting in a decrease in Cmax by approximately 25% to 30% and an increase in Tmax to approximately 3 hours. However, administration of pregabalin with food has no clinically relevant effect on the total amount of pregabalin absorbed. Therefore, pregabalin can be taken with or without food.

Drug-Herb Interactions

LYRICA has no known drug-herb interactions.

Drug-Laboratory Interactions

LYRICA has no known drug-laboratory test interactions.

Dosage And Administration

Dosing Considerations

Patients with Impaired Renal Function

Pregabalin is primarily eliminated from the systemic circulation by renal excretion as unchanged drug. In some elderly patients and those with a medical history of significant renal insufficiency, daily dosages should be reduced accordingly (see Dosage Adjustment Based on Renal Function, below).

In accordance with current clinical practice, if LYRICA (pregabalin) has to be discontinued, it is recommended this should be done gradually over a minimum of 1 week (see WARNINGS AND PRECAUTIONS, Abrupt or Rapid Discontinuation).

Adults:

Neuropathic Pain Associated with Diabetic Peripheral Neuropathy

The recommended starting dose for LYRICA is 150 mg/day, given in two or three divided doses (75 mg BID or 50 mg TID), with or without food in patients with a creatinine clearance rate of at least 60 mL/min. Efficacy of LYRICA has been demonstrated within the first week. Based on individual patient response and tolerability, the dose may be increased to 150 mg BID (300 mg/day) after one week.

For patients who experience significant and ongoing pain and can tolerate pregabalin 300 mg/day well, maximum daily dose of 600 mg (300 mg twice a day, BID) can be used. However, in clinical trials, LYRICA 600 mg/day did not provide additional significant efficacy and patients treated with this dose experienced markedly higher rates of adverse events and discontinued the trial more frequently (see ADVERSE REACTIONS, Tables 1 and 5). Doses above 600 mg/day have not been studied and are not recommended.

Neuropathic Pain Associated with Postherpetic Neuralgia

The recommended starting dose for LYRICA is 150 mg/day, given in two or three divided doses (75 mg BID or 50 mg TID), with or without food in patients with a creatinine clearance rate of at least 60 mL/min. Efficacy of LYRICA has been demonstrated within the first week. Based on individual patient response and tolerability, the dose may be increased to 150 mg BID (300 mg/day) after one week.

For patients who experience significant and ongoing pain and can tolerate pregabalin 300 mg/day well, maximum daily dose of 600 mg (300 mg twice a day, BID) can be used. However, in clinical trials, LYRICA 600 mg/day did not provide additional significant efficacy and patients treated with this dose experienced markedly higher rates of adverse events and discontinued the trial more frequently (see ADVERSE REACTIONS, Tables 3 and 6). Doses above 600 mg/day have not been studied and are not recommended.

Neuropathic Pain Associated with Spinal Cord Injury

The recommended starting dose for LYRICA is 150 mg/day, given in two divided doses (75 mg BID), with or without food in patients with a creatinine clearance rate of at least 60 mL/min. Efficacy of LYRICA has been demonstrated within the first week. Based on individual patient response and tolerability, the dose may be increased to 150 mg BID (300 mg/day) after one week.

For patients who experience significant and ongoing pain and can tolerate pregabalin 300 mg/day well, a maximum daily dose of 600 mg (300 mg twice a day, BID) may be considered. Doses above 600 mg/day have not been studied and are not recommended.

Pain Associated with Fibromyalgia

The recommended dosage is 300 to 450 mg/day, given in two divided doses. The recommended starting dose for LYRICA is 150 mg/day, given in two divided doses (75 mg BID), with or without food in patients with a creatinine clearance rate of at least 60 mL/min. Based on individual response and tolerability, the dose may be increased to 150 mg BID (300 mg/day) after one week. Patients who do not experience sufficient benefit with 300 mg/day may be further increased to 225 mg BID (450 mg/day). In some patients, efficacy of LYRICA has been demonstrated within the first week.

For patients who experience significant and ongoing pain and can tolerate pregabalin 300 mg/day well, maximum daily dose of 600 mg (300 mg twice a day, BID) can be used. However, in clinical trials of fibromyalgia, LYRICA 600 mg/day did not provide additional significant efficacy and patients treated with this dose experienced significantly higher rates of adverse events and discontinued the trial more frequently (see ADVERSE REACTIONS, Tables 7 and 10). In view of the dose-related adverse events, the decision to treat patients with doses above 450 mg/day should be based on clinical judgment of the treating physician. Doses above 600 mg/day have not been studied and are not recommended.

Dosage Adjustment Based on Renal Function

LYRICA is primarily eliminated by renal excretion. Therefore, the dose should be adjusted for patients with reduced renal function. Pregabalin clearance is directly proportional to creatinine clearance. Therefore, dosing adjustment should be based on creatinine clearance (CLCr), as indicated in Table 13.

To use this dosing table, an estimate of the patient's creatinine clearance (CLCr) in mL/min is needed. CLCr in mL/min may be estimated from serum creatinine (mg/dL) determination using the Cockcroft and Gault equation:

CLCr= [140 - age (years)] x weight(kg) ( x 0.85 for female patients)
          72 x serum creatinine (mg/dL)

Pregabalin is effectively removed from plasma by hemodialysis. Over a 4-hour hemodialysis treatment, plasma pregabalin concentrations are reduced by approximately 50%. For patients receiving hemodialysis, pregabalin daily dose should be adjusted based on renal function. In addition to the daily dose adjustment, a supplemental dose should be given immediately following every 4-hour hemodialysis treatment (see Table 13).

Table 13. Pregabalin Dosage Adjustment Based on Renal Function

Creatinine
Clearance (CLcr)
(mL/min)

Total Pregabalin Daily Dose (mg/day)a

Recommended Dose Escalation*

Dose Regimen

 

Starting Dose


up to

Maximum daily dose

 

≥60

150

300

450

600

BID or TID

30-60

75

150

225

300

BID or TID

15-30

25-50

75

100-150

150

QD or BID

<15

25

25-50

50-75

75

QD

Supplementary dosage following hemodialysis (mg)b

Patients on the 25 mg QD regimen: take one supplemental dose of 25 mg or 50 mg
Patients on the 25-50 mg QD regimen: take one supplemental dose of 50 mg or 75 mg
Patients on the 50-75 mg QD regimen: take one supplemental dose of 75 mg or 100 mg
Patients on the 75 mg QD regimen: take one supplemental dose of 100 mg or 150 mg

TID = Three divided doses; BID = Two divided doses; QD = Single daily dose.
* Based on individual patient response and tolerability.
a Total daily dose (mg/day) should be divided as indicated by dose regimen to provide mg/dose.
b Supplementary dose is a single additional dose.

Geriatrics (> 65 years): Pregabalin oral clearance tended to decrease with increasing age. This decrease in pregabalin oral clearance is consistent with age-related decreases in creatinine clearance. Reduction of pregabalin dose may be required in patients who have age-related compromised renal function.

Pediatrics (<18 years of age): The safety and efficacy of pregabalin in pediatric patients (<18 years of age) have not been established and its use in this patient population is not recommended.

Administration

LYRICA (pregabalin) is given orally with or without food (see DRUG INTERACTIONS, Drug Food Interactions).

Overdosage

For management of a suspected drug overdose, contact your regional Poison Control Centre.

Signs, Symptoms and Laboratory Findings of Acute Overdosage in Humans

The highest known dose of pregabalin received in the clinical development program in which there was no fatal outcome was 15,000 mg in 1 patient. The types of adverse events experienced by patients who received an overdose were not clinically different from other patients receiving recommended doses of pregabalin.

In post-marketing experience, fatal outcomes in cases in which pregabalin has been taken in combination with other medications have been reported with a pregabalin overdose as low as 800 mg in a day. In none of these cases has pregabalin been established as the cause of death or in pregabalin monotherapy. The lowest fatal dose with pregabalin alone has not yet been identified.

The most commonly reported adverse events observed when pregabalin was taken in overdose (dose range from 800 mg/day up to 11,500 mg as a single dose) included affective disorder, somnolence, confusional state, depression, agitation, and restlessness.  Seizures were also reported.

Treatment or Management of Overdose

There is no specific antidote for overdose with pregabalin. If indicated, elimination of unabsorbed drug may be attempted by emesis or gastric lavage; usual precautions should be observed to maintain the airway. General supportive care of the patient is indicated including monitoring of vital signs and observation of the clinical status of the patient. A Certified Poison Control Center should be contacted for up-to-date information on the management of overdose with pregabalin.

Hemodialysis

Standard hemodialysis procedures result in significant clearance of pregabalin (approximately 50% in 4 hours) and should be considered in cases of overdose. Although hemodialysis has not been performed in the few known cases of overdose, it may be indicated by the patient's clinical state or in patients with significant renal impairment.

Action And Clinical Pharmacology

Mechanism of Action

LYRICA (pregabalin) binds to the α2-δ subunit of the voltage-gated calcium channels in central nervous system tissues. In vitro, pregabalin reduces calcium influx at nerve terminals, which may inhibit the release of excitatory neurotransmitters such as glutamate. Through this mechanism, LYRICA may modulate nerve impulses involved in the transmission of pain. However, the clinical relevance of these findings in man is unknown.

Pharmacodynamics

LYRICA binds with high affinity to the alpha2-delta protein (a calcium channel subunit) of brain tissues and has analgesic, antiepileptic, and anxiolytic activity. Pregabalin is known chemically as (S)-3-(aminomethyl)-5-methylhexanoic acid.

Although the mechanism of action of pregabalin is unknown, results with genetically modified mice and with compounds structurally-related to pregabalin indicate that selective binding to the alpha2-delta protein is required for analgesic, antiepileptic and anxiolytic action in animal models. In vitro, pregabalin reduces the release of several neurotransmitters, suggesting a modulatory action on calcium channel function.

Pregabalin does not mimic GABA at GABAA or GABAB receptors, nor does it augment GABAA responses like benzodiazepines or barbiturates. In contrast to vascular calcium channel blockers, pregabalin does not alter systemic blood pressure or cardiac function. Various in vitro and in vivo results differentiate pregabalin from GABA uptake inhibitors or GABA transaminase inhibitors. In addition, pregabalin does not block sodium channels, it is not active at opiate receptors, it does not alter cyclooxygenase enzyme activity, it is not a serotonin agonist, it is not a dopamine antagonist, and it is not an inhibitor of dopamine, serotonin or noradrenaline reuptake.

Pregabalin treatment reduces pain-related behavior in neuropathic animal models of diabetes, peripheral nerve damage or chemotherapeutic insult and in a model of musculoskeletal-associated pain. Pregabalin given intrathecally prevents pain-related behaviors and reduces pain-related behavior caused by spinally administered agents, suggesting that it acts directly on tissues of the spinal cord or brain.

Pharmacokinetics

All pharmacological actions following pregabalin administration are due to the activity of the parent compound; pregabalin is not appreciably metabolized in humans. Mean steady-state plasma pregabalin concentration-time profiles following 75, 300, and 600 mg/day given in equally divided doses every 8 hours (TID) and 600 mg/day given in equally divided doses every 12 hours (BID) are shown in Table 14. Pregabalin pharmacokinetics are linear over the recommended daily dose range. Inter-subject pharmacokinetic variability for pregabalin is low (<20%).

Table 14. Pregabalin Mean (CV%a) Steady-State Pharmacokinetic Parameter Values in Healthy Volunteers

Dose(mg)

Regimen

Daily Dose (mg/day)

N

Cmaxss
(μg/mL)

tmax (hr)

Cminss
(μg/mL)

AUC(0-t)

(μg~hr/mL)

t2 (hr)

CL/F

(mL/min)

25

TIDb

75

8

1.39

0.9

0.45

6.7

5.9

64.1

 

-19.5

-34.2

-25

-18.3

-17.3

-16.1

100

TID

300

6

5.03

0.8

1.94

25.2

6.3

68.9

 

-21.3

-31

-33.6

-23

-19.6

-20.9

200

TID

600

11

8.52

0.9

3.28

41.7

6.3

81

    

-14.8

-22.2

-29.2

-12.8

-13.6

-11.7

300

BIDc

600

8

9.07

1.4

2.6

59

6.7

85.1

    

-10.5

-57.1

-15.5

-6.4

-16.2

-6.4

Cmaxss: Steady-state peak plasma concentration.
tmax: Time of peak plasma concentration at steady state.
Cminss: Steady-state trough plasma concentration
AUC(0-t): Area under the plasma concentration-time curve during one dosing interval at steady state
t2: Elimination half-life
CL/F: Oral clearance
a: Percent coefficient of variation
b: Total daily dose given in equally divided doses every 8 hours
c: Total daily dose given in equally divided doses every 12 hours

Absorption: Pregabalin is rapidly absorbed when administered in the fasted state, with peak plasma concentrations occurring within 1.5 hours following both single- and multiple-dose administration. Pregabalin oral bioavailability is ≥ 90% and is independent of dose. Cmax (Figure 1) and AUC values increase proportionally following single- and multiple-dose administration. Following repeated administration, steady state is achieved within 24 to 48 hours. Multiple dose pharmacokinetics are predictable from single-dose data.

Figure 1. Individual and Mean Steady-State Pregabalin Cmax Values Following 75, 300 and 600 mg/day Given in Equally Divided Doses TID (q8h) to Healthy Volunteersa

a: Solid line is the regression line going through the origin; individual (□ ) and mean (♦) values.

Distribution: In preclinical studies, pregabalin has been shown to readily cross the blood brain barrier in mice, rats, and monkeys. Pregabalin is a substrate for system L transporter which is responsible for the transport of large amino acids across the blood-brain barrier. Pregabalin has been shown to cross the placenta in rats and is present in the milk of lactating rats. In humans, the apparent volume of distribution of pregabalin following oral administration is approximately 0.5L/kg. Pregabalin is not bound to plasma proteins. At clinically efficacious doses of 150 and 600mg/day, the average steady-state plasma pregabalin concentrations were approximately 1.5 and 6.0 μg/mL, respectively.

Metabolism: Pregabalin undergoes negligible metabolism in humans. Following a dose of radiolabeled pregabalin, approximately 98% of the radioactivity recovered in the urine was unchanged pregabalin. The N-methylated derivative of pregabalin, the major metabolite of pregabalin found in urine, accounted for 0.9% of the dose. In preclinical studies, pregabalin (S- enantiomer) did not undergo racemization to the R-enantiomer in mice, rats, rabbits, or monkeys.

Excretion: Pregabalin is eliminated from the systemic circulation primarily by renal excretion as unchanged drug. Pregabalin mean t½ is 6.3 hours. Pregabalin elimination is proportional to creatinine clearance. Pregabalin clearance is reduced in patients with impaired renal function (see DOSAGE AND ADMINISTRATION).

Special Populations and Conditions

Pregabalin undergoes negligible metabolism, is not bound to plasma proteins, and is eliminated predominately as unchanged drug by renal excretion. Clinically important differences in pregabalin pharmacokinetics due to race and gender have not been observed and are not anticipated.

Pediatrics: Pharmacokinetics of pregabalin have not been studied in paediatric patients.

Geriatrics: Pregabalin oral clearance tended to decrease with increasing age. This decrease in pregabalin oral clearance is consistent with age-related decreases in creatinine clearance. Reduction of pregabalin dose may be required in patients who have age-related compromised renal function (see WARNINGS AND PRECAUTIONS and DOSAGE AND ADMINISTRATION).

Gender: A population pharmacokinetic analysis of the Phase 2/3 clinical program showed that the relationship between daily dose and pregabalin drug exposure is similar between genders when adjusted for gender-related differences in creatinine clearance.

Race: A population pharmacokinetic analysis of the Phase 2/3 clinical program showed that the relationship between daily dose and pregabalin drug exposure is similar among Caucasians, Blacks, and Hispanics.

Renal Insufficiency: Because renal elimination is the major elimination pathway, dosage reduction in patients with renal dysfunction is necessary. Pregabalin is effectively removed from plasma by hemodialysis. Following a 4-hour hemodialysis treatment, plasma pregabalin concentrations are reduced by approximately 50%. For patients on hemodialysis, dosing must be modified (see DOSAGE AND ADMINISTRATION).

Storage And Stability

Store at 15°C-30°C.

Dosage Forms, Composition And Packaging

Dosage Forms

LYRICA (pregabalin) is supplied as a hard gelatin capsule for daily oral administration.

25 mg capsules: White hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 25” on the body.

50 mg capsules: White hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 50” and an ink band on the body.

75 mg capsules: White/orange hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 75” on the body.

100 mg capsules: Orange hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 100” on the body. §

150 mg capsules: White hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 150” on the body.

200 mg capsules: Light orange hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 200” on the body. §

225 mg capsules: White/light orange hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 225” on the body.

300 mg capsules: White/orange hard gelatin capsule printed with black ink “Pfizer” on the cap, “PGN 300” on the body.

§ Not commercially available in Canada

Composition

Each capsule of LYRICA contains 25, 50, 75, 100§, 150, 200§, 225, or 300 mg pregabalin, lactose monohydrate, maize starch, and talc. The capsule shells contain gelatin and titanium dioxide. In addition, the orange capsule shells contain red iron oxide and the white capsule shells contain sodium lauryl sulfate and colloidal silicon dioxide. Colloidal silicon dioxide is a manufacturing aid, which may not be present. The markings on the capsules are in black ink, which contains shellac, black iron oxide, propylene glycol, potassium hydroxide and water.

§ Not commercially available in Canada

Packaging

Capsules are packaged in HDPE bottles containing 60 capsules, and PVC/ aluminum blisters.

 

Control #: 198215
December 6, 2016

 

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