Baclofen withdrawal

Background

• Baclofen (Lioresal) is an anti-spasmodic that works on the as a GABA-B agonist
• Primarily used in patients with multiple sclerosis, cerebral palsy, and spinal cord injuries
• Often administered intrathecally but does have an oral formulation
• Withdrawal symptoms thought to be caused by decreased GABA activation

Clinical Features

Baclofen withdrawal especially in the case of acute intrathecal pump failure may lead to:

• High fevers
• Confusion, altered mental status
• Muscle stiffness
• Seizures
• Rhabdomyolysis
• Multiple organ system failure
• Death

Differential Diagnosis

• Sepsis
• Meningitis
• Epilepsy
• Autonomic dysreflexia
• Neuroleptic malignant syndrome
• Malignant hyperthermia

Sedative/hypnotic withdrawal

• Toxic alcohols
  • Ethanol
  • Ethylene glycol
  • Methanol
  • Isopropyl alcohol
• Benzodiazepines
  • Flunitrazepam (Rohypnol)
• Gamma hydroxybutyrate (GHB)
• Baclofen
• Barbiturates
• Opioids
• Chloral hydrate

Evaluation

• History of baclofen use
• Physical exam
• Examination of the pump
• CPK levels
• Electrolytes
• CBC
• LFTs
• Coagulation studies

Management

• High doses of benzodiazepines are the mainstay of treatment
• High dose oral baclofen has been used but has been less effective
• Intrathecal baclofen bolus can be attempted but overdoses are possible with this method
• Dantrolene and cyproheptadine can also be considered but their efficacy is still unproven in this situation

Disposition

Admit:

• Organ failure
• Status epilepticus
• Pump malfunction
• Fever
• Loss of consciousness

See Also

• Cerebral palsy
• Baclofen toxicity
• Baclofen