First Author: Omaima Chaudhary, M.D. Co-Author: Faysal Sadeq, M.D. – Resident Physician, The Wright Center for GME Co-Author: Vaibhavi Polavarapu, M.D. – Resident Physician, The Wright Center for Graduate Medical Education Co-Author: Erin McFadden, M.D. – Physician, The Wright Center for GME
Introduction: Pregabalin withdrawal is uncommon, especially in patients taking therapeutic doses. We present a case of withdrawal requiring intensive care unit (ICU) admission despite prescribed use.
Description: A 78-year-old male with hypertension, hyperlipidemia, chronic obstructive pulmonary disease, and peripheral neuropathy presented with epigastric pain, vomiting, and constipation. Laboratory results, including liver enzymes and lipase, were unremarkable. Computed tomography of the abdomen/ pelvis was consistent with small bowel obstruction. He was started on intravenous (IV) fluids, kept nothing by mouth (NPO), and a nasogastric tube was placed. On day three, he developed dyspnea, palpitations, diaphoresis, and dry heaves. Blood pressure (BP) was 196/76 mmHg with a heart rate of 68 beats per minute. Troponin was elevated at 21.6 ng/L but remained flat on serial testing. Creatinine was elevated at 1.6 mg/dL. Electrocardiogram showed sinus rhythm with non-specific ischemic changes. Chest x-ray revealed pulmonary edema. He was transferred to the ICU and started on IV labetalol for BP control. No clear etiology was found until the pharmacist noted that the patient's pregabalin was being held due to NPO status. The patient was restarted on his home dose of pregabalin 100 mg twice daily, with complete resolution of symptoms within hours.
Discussion: Pregabalin is a neuroinhibitory agent that binds to calcium channels, reducing excitatory neurotransmitter release. Commonly prescribed for neuropathic pain, it is a federally controlled substance due to its potential for dependence. Withdrawal symptoms—especially with abrupt discontinuation—include anxiety, diaphoresis, hypertension, tremors, and rarely seizures. Most reports involve misuse or high doses; however, this case demonstrates serious withdrawal effects from prescribed use. There are no parenteral formulations of gabapentinoids approved in the United States, and no established protocols for withdrawal prevention in NPO patients. Therefore, for patients who must be kept NPO, the only available approach is close monitoring and symptomatic management. This case emphasizes the risk of severe pregabalin withdrawal at therapeutic doses and the need for clear protocols in hospitalized patients who cannot take oral medications.
