From the Guidelines
For chronic muscle spasticity while on baclofen, consider adding tizanidine or botulinum toxin injections to help reduce spasticity with potentially less sedation. When managing chronic spasticity, it's crucial to balance the need for spasticity control with the potential for sedation, especially in patients already on baclofen. According to the guidelines for adult stroke rehabilitation and recovery from the American Heart Association/American Stroke Association 1, targeted injection of botulinum toxin into localized muscles is recommended to reduce spasticity and improve range of motion, with a Class I, Evidence A recommendation. Tizanidine, as suggested in the management of adult stroke rehabilitation care guideline 1, can be considered for spasticity, especially in chronic stroke patients, offering an alternative to increasing baclofen doses, which might exacerbate sedation. Key considerations for managing spasticity with minimal sedation include:
- Using botulinum toxin injections for localized spasticity
- Considering tizanidine for generalized spasticity
- Implementing physical therapy techniques such as stretching, heat therapy, and massage
- Strategically timing baclofen doses to minimize daytime sedation These approaches can help manage spasticity effectively while minimizing the risk of sedation, thus improving the patient's quality of life and functional outcomes.
From the FDA Drug Label
Patients should also be instructed that the sedation may be additive when tizanidine is taken in conjunction with drugs (baclofen, benzodiazepines) or substances (e.g., alcohol) that act as CNS depressants. The answer is tizanidine.
- Key points:
- Tizanidine can be used to assist with chronic spasticity of the muscle.
- It may have additive sedative effects when taken with baclofen.
- To decrease sedation, caution should be exercised when co-administering tizanidine with baclofen 2.
From the Research
Alternatives to Decrease Sedation while on Baclofen
To assist with chronic spasticity of the muscle while on baclofen and decrease sedation, several alternatives can be considered:
- Tizanidine: Studies have found that tizanidine has equivalent efficacy to baclofen in treating spasticity, but with better tolerability and less frequent weakness 3.
- Botulinum toxin type A: This has been shown to be an effective therapeutic option for spasticity caused by spinal cord injury, with improved modified Ashworth scale scores and disability assessment scale scores 4.
- Intrathecal baclofen: Delivering baclofen directly into the cerebrospinal fluid can optimize its efficacy while minimizing drug-related side-effects, including sedation 5, 6.
- Other pharmacological treatments: Diazepam, dantrolene sodium, and gabapentin are also used to treat spasticity, although their effectiveness and individual value may vary 7.
Considerations for Treatment
When considering alternative treatments, it is essential to weigh the benefits and risks of each option:
- Efficacy: The ability of the treatment to improve spasticity and reduce sedation.
- Tolerability: The frequency and severity of adverse effects, such as weakness, nausea, and somnolence.
- Individual patient needs: The underlying disease or severity of spasticity, as well as the patient's medical history and current medications.