How to manage worsening spasticity and insomnia in a patient with End-Stage Renal Disease (ESRD) on Hemodialysis (HD) and a history of old Middle Cerebral Artery (MCA) infarct, who was previously on baclofen 5mg twice daily (BD)?

Management of Worsening Spasticity and Insomnia in ESRD Patient Previously on Baclofen

For a patient with ESRD on hemodialysis with worsening spasticity and insomnia after baclofen discontinuation, tizanidine should be used as the first-line pharmacological agent rather than restarting baclofen, due to baclofen's significant risk of toxicity in renal failure. 1, 2

Understanding the Problem

This patient presents with two key issues:

1. Worsening spasticity after baclofen discontinuation
2. Insomnia (likely related to spasticity and/or withdrawal)

Why Baclofen Was Discontinued

• Baclofen is primarily excreted unchanged through the kidneys 3
• In ESRD patients, baclofen can accumulate to toxic levels even at low doses 4, 5, 2
• Multiple studies demonstrate that even a single dose of baclofen can cause neurotoxicity in ESRD patients 5
• Symptoms of baclofen toxicity include altered mental status, decreased consciousness, and hemodynamic instability 2, 6

Management Algorithm

Step 1: Non-Pharmacological Management

• Implement positioning, passive stretching, and range-of-motion exercises several times daily 7, 1
• Consider splinting or serial casting if contractures are developing 7
• Functional electrical stimulation can be used as an adjunctive therapy 7, 1

Step 2: First-Line Pharmacological Management

• Tizanidine (starting at low doses, 2mg once daily, gradually titrating up)
  • Specifically recommended for chronic stroke patients 7, 1
  • Less dependent on renal clearance than baclofen
  • Effective for short-duration relief for specific activities 1

Step 3: Alternative Pharmacological Options

• Dantrolene can be considered if cognitive side effects must be minimized 7, 1
  • Start at low doses (25mg daily) and titrate slowly
  • Monitor for hepatotoxicity

Step 4: For Focal Spasticity

• Botulinum toxin injections (100-300 IU) for specific muscle groups 1
  • Particularly effective for ankle spasticity
  • Requires specialist administration

Step 5: Management of Insomnia

• Avoid benzodiazepines as they may have deleterious effects on stroke recovery 7
• Consider non-benzodiazepine sleep aids at low doses with careful monitoring
• Address pain with acetaminophen if contributing to insomnia 1

Special Considerations for ESRD Patients

• Hemodialysis schedule: Coordinate medication administration with dialysis schedule to prevent accumulation
• Medication dosing: Start at lower doses and titrate slowly
• Monitoring: Regular assessment of efficacy, side effects, and functional outcomes 1
• Identify and treat factors that can worsen spasticity (skin pressure sores, fecal impaction, urinary tract infections) 1

Cautions and Pitfalls

1. Never restart baclofen in this ESRD patient - multiple case reports show that baclofen should be avoided in patients with severely reduced kidney function (eGFR <30mL/min/1.73m²) or on renal replacement therapy 2

2. Watch for withdrawal symptoms - The patient may be experiencing baclofen withdrawal, which can include anxiety, agitation, insomnia, and increased spasticity 1

3. Careful dose titration - Start with lower doses of alternative medications and titrate slowly while monitoring for side effects

4. Regular reassessment - Treatment should focus on improving pain, skin hygiene, and function rather than just reducing muscle tone 1

By following this approach, the patient's spasticity and insomnia can be effectively managed while avoiding the significant risks associated with baclofen use in ESRD.