From the Guidelines
Baclofen withdrawal should be managed by immediately resuming the intrathecal infusion as soon as possible to prevent catastrophic withdrawal syndrome, and supportive measures including high-dose benzodiazepine intravenous infusion or oral baclofen may be lifesaving. The management of baclofen withdrawal is crucial to prevent potentially life-threatening symptoms. According to the most recent evidence 1, abrupt reduction in gamma-aminobutyric acid agonist activity in the central nervous system following abrupt cessation of baclofen infusion can lead to a catastrophic intrathecal baclofen withdrawal syndrome. This syndrome usually evolves over 1–3 days but may become fulminant if not recognised and treated promptly.
Some key points to consider in managing baclofen withdrawal include:
- Resuming the intrathecal infusion as soon as possible to prevent withdrawal syndrome
- Using supportive measures such as high-dose benzodiazepine intravenous infusion or oral baclofen to manage symptoms
- Monitoring patients for withdrawal symptoms, including agitation, hallucinations, seizures, hyperthermia, autonomic instability, and psychosis
- Considering hospitalization for severe withdrawal cases, with supportive care and benzodiazepines to manage symptoms
The physiological basis for these recommendations stems from baclofen's action as a GABA-B receptor agonist; abrupt discontinuation leads to sudden reduction in GABA-mediated inhibition, resulting in neuronal hyperexcitability and autonomic instability, as noted in a recent consensus statement 1. Patients with renal impairment require more cautious management as baclofen is primarily excreted by the kidneys, and withdrawal symptoms may be prolonged in these individuals.
In terms of specific treatment, reinstating baclofen at the previous effective dose and then implementing a gradual taper, typically reducing by 5-10mg every 3-7 days depending on the patient's response and initial dose, may be necessary. Additionally, GABA-ergic medications like gabapentin or phenobarbital may be used as adjunctive therapy to manage symptoms. It is essential to plan perioperative management of patients receiving intrathecal baclofen with input from a specialist in this area to prevent significant withdrawal symptoms.
From the FDA Drug Label
WARNINGS a. Neonatal Withdrawal Symptoms:Withdrawal symptoms have been reported starting hours to days after delivery in neonates whose mothers were treated with oral baclofen throughout pregnancy. The symptoms of withdrawal in these infants have included increased muscle tone, tremor, jitteriness, and seizure b. Abrupt Drug Withdrawal:Hallucinations and seizures have occurred on abrupt withdrawal of baclofen Therefore, except for serious adverse reactions, the dose should be reduced slowly when the drug is discontinued.
Baclofen Withdrawal Signs and Symptoms:
- Increased muscle tone
- Tremor
- Jitteriness
- Seizure
- Hallucinations
Recommendations for Managing Baclofen Withdrawal:
- The dose should be reduced slowly when the drug is discontinued, except for serious adverse reactions 2.
- Gradually reduce the dose and discontinue baclofen before delivery if the potential benefit justifies the potential risk to the fetus and oral baclofen is continued during pregnancy 2.
From the Research
Baclofen Withdrawal Signs and Symptoms
- Increased spasticity, agitation, confusion, hallucinations, and seizures can occur after abrupt cessation of baclofen, especially in patients with renal insufficiency or those taking high doses for a long time 3
- Baclofen withdrawal syndrome is a serious complication with potential for rapid progression and significant morbidity and mortality, characterized by neurological, autonomic, and psychiatric symptoms 4
- Delirium, a common presentation of baclofen withdrawal, can be difficult to distinguish from delirium of other etiologies and may lead to significant morbidity and mortality if left unrecognized or inadequately treated 5
- Severe cases of baclofen withdrawal can mimic meningoencephalitis, seizure disorder, or neuroleptic malignant syndrome, and may require mechanical ventilation 6
Management of Baclofen Withdrawal
- Gradual tapering of baclofen is recommended to avoid symptomatic adverse effects 3
- Reinstatement of baclofen can lead to complete resolution of delirium symptoms 5
- Supportive interventions, such as reducing complications of delirium, are crucial in managing patients experiencing baclofen-withdrawal delirium 5
- Treatment options for severe cases include re-administration of baclofen, or use of benzodiazepines, propofol, or dexmedetomidine, although no specific guidelines have been established 6
- Establishing management protocols for managing anticipated interruption of oral or intrathecal baclofen is necessary, as approximately 75% and 35% of respondents lack established protocols, respectively 7