Low-Dose Pregabalin as Adjunctive Therapy in Assisting Benzodiazepine Discontinuation: Two Case Reports in Geriatric Inpatient and Outpatient Setting

Abstract

<h3>Introduction</h3> Benzodiazepine use in the elderly remained common despite increasing evidence suggesting its potential risk. Furthermore, both physicians and patients are wary of discontinuing benzodiazepines and many patients do not tolerate full benzodiazepine taper. Pregabalin has been demonstrated to be effective in treating patients who do not respond to conventional treatment for generalized anxiety disorder. Pregabalin has helped reduced anxiety symptoms when used in augmentation with selective serotonin reuptake inhibitors (SSRIs), and in some cases may be recommended for initial treatment when SSRI use is inappropriate. Pregabalin has been used as an adjunctive therapy to benzodiazepine discontinuation with mixed results, and one randomized controlled trial that showed a negative result was not done in the geriatric population. <h3>Methods</h3> We present two case reports using pregabalin as an adjunctive therapy towards benzodiazepine discontinuation; one in an inpatient unit, while the other in an outpatient clinic. <h3>Results</h3> Two case reports of patients in their 70s are illustrated as following: Ms A was admitted to our inpatient unit after nortriptyline overdose requiring medication intervention. Her medication is switched to quetiapine and lithium, with lorazepam 0.5mg daily as needed was added to address extreme anxiety in the unit. Despite reporting improved mood, patient continuously asks for lorazepam and she agreed to be crosstitrated to pregabalin instead due to concerns of side effects on long term benzodiazepine use. Patient was able to tolerate pregabalin at 100mg, no longer required lorazepam. Pregabalin is continued in outpatient setting and patient is not prescribed any benzodiazepine. Ms B, on the other hand, started treatment in the outpatient clinic following referral from her primary care physician due to worsening anxiety and depressive symptoms. She mentioned paroxetine was no longer helpful, and was prescribed lorazepam 0.5mg three times daily as needed by her PCP to alleviate her anxiety. However, she started having memory issues with daily lorazepam use, and she fears misues as she has hoarded diazepam in the past. Patient is seen weekly for psychodynamic psychotherapy and medication management. Initially, patient was crosstitrated from paroxetine to mirtazapine with good response, yet she still used lorazepam on average 0.5 mg twice daily. She agrees to start pregabalin, which was eventually uptitrated to 75mg with good response to her sleep and anxiety symptoms alongside mirtazapine 45mg. Her most recent Montreal Cognitive Assessment is 29/30. She has since returned to work and did not report any issues or need to use lorazepam. <h3>Conclusions</h3> These two cases demonstrate that low-dose pregabalin may be used to help geriatric patients to discontinue benzodiazepine use with good safety profile and tolerability. <h3>This research was funded by</h3> The author did not receive any fundings for this research.