What muscle relaxer is suitable for a patient taking lithium, Suboxone (buprenorphine/naloxone), buspirone, and hydrocortisone?

From the Guidelines

Cyclobenzaprine (Flexeril) is the most appropriate muscle relaxant choice for a patient taking lithium, suboxone, buspirone, and hydroxyzine, due to its efficacy and relatively safer profile compared to other options, as evidenced by a higher-quality Cochrane review 1. A typical starting dose would be 5-10 mg taken orally up to three times daily as needed for muscle spasm, not exceeding 30 mg per day, with treatment generally limited to 2-3 weeks. This medication should be used cautiously due to potential additive central nervous system depression with suboxone and sedative effects with hydroxyzine. Some key points to consider when prescribing cyclobenzaprine include:

• Monitoring for excessive sedation, dizziness, and confusion, particularly in the first few days of treatment 1
• Avoiding alcohol completely while taking this combination of medications due to dangerous CNS depression risk
• Incorporating non-pharmacological approaches like physical therapy, gentle stretching, heat therapy, and massage into the treatment plan to minimize the need for medication
• Considering baclofen (10 mg three times daily) as an alternative if cyclobenzaprine is not tolerated, although evidence for its use in low back pain is sparse 1
• Avoiding tizanidine due to significant drug interactions with this medication regimen and higher rates of adverse events compared to placebo 1

From the FDA Drug Label

Muscle Relaxants Clinical Impact: Buprenorphine may enhance the neuromuscular blocking action of skeletal muscle relaxants and produce an increased degree of respiratory depression Intervention: Monitor patients for signs of respiratory depression that may be greater than otherwise expected, decrease the dosage of buprenorphine hydrochloride and/or the muscle relaxant as necessary.

• Muscle relaxants may increase the risk of respiratory depression when used with buprenorphine (Suboxone).
• It is recommended to monitor patients for signs of respiratory depression and adjust the dosage of buprenorphine and/or the muscle relaxant as necessary.
• Lithium may also prolong the effects of neuromuscular blocking agents, which is a concern when using muscle relaxants.
• Given the patient's medications, including lithium, Suboxone, buspirone, and hydrocerin, it is essential to exercise caution when prescribing a muscle relaxant.
• A conservative approach would be to avoid using a muscle relaxant or to monitor the patient closely for signs of respiratory depression and adjust the treatment plan accordingly 2.

From the Research

Medication Interactions

• The patient is currently taking lithium, suboxone, buspirone, and hydrocerin, and requires a muscle relaxer.
• There is no direct evidence in the provided studies regarding the use of muscle relaxers with this specific combination of medications.
• However, it is essential to consider potential interactions between medications, particularly with lithium, which can have significant interactions with other drugs.

Serotonin Syndrome Risk

• The patient is taking buspirone, which can increase serotonin activity, and lithium, which can also affect serotonin levels 3.
• Although there is no direct evidence of an interaction between buspirone, lithium, and muscle relaxers, it is crucial to be aware of the potential risk of serotonin syndrome when combining medications that affect serotonin activity.

Lack of Relevant Evidence

• The provided studies do not directly address the use of muscle relaxers with the patient's current medication regimen.
• One study discusses the risk of serotonin syndrome with the combination of bupropion and SSRIs 3, while the other study compares the effectiveness of lithium with antipsychotics or anticonvulsants for bipolar disorder 4.
• Neither study provides guidance on the safe use of muscle relaxers with the patient's current medications.