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 After Baclofen Discontinuation

Botulinum toxin injections are recommended as the first-line treatment for focal spasticity in this ESRD patient on hemodialysis, as baclofen is contraindicated due to the high risk of toxicity in renal failure. 1, 2

Assessment and Immediate Management

• Recognize withdrawal syndrome: The patient's worsening spasticity and insomnia likely represent baclofen withdrawal symptoms, which can be severe and potentially life-threatening
• Evaluate severity: Assess for other withdrawal symptoms including anxiety, agitation, hallucinations, delirium, fever, tremors, tachycardia, and seizures 2
• Rule out exacerbating factors: Check for pressure sores, fecal impaction, urinary tract infections, or bladder stones that can worsen spasticity 2

Treatment Algorithm for Spasticity Management

First-line Approach:

1. Botulinum toxin injections for focal spasticity affecting specific muscle groups (100-300 IU based on affected muscles) 1, 2
   • Particularly effective for painful spasticity that impairs function or compromises positioning
   • Does not undergo renal elimination, making it safer in ESRD

Non-pharmacological Interventions:

• Implement positioning, passive stretching, and range-of-motion exercises several times daily 2
• Consider splinting or serial casting if contractures are developing 2
• Functional electrical stimulation as adjunctive therapy 1, 2

Alternative Pharmacological Options (with caution):

• Tizanidine: Start at very low doses (0.5-1mg once daily) with careful titration and close monitoring
  • Less renal elimination than baclofen but still requires dose adjustment in ESRD
• Dantrolene: Consider if cognitive side effects must be minimized, starting at 25mg daily with slow titration 2
  • Monitor for hepatotoxicity

Avoid:

• Oral baclofen: Contraindicated in ESRD due to high risk of toxicity even at low doses 3, 4, 5, 6
• Benzodiazepines: May have deleterious effects on stroke recovery 2

Management of Insomnia

1. Address underlying causes:

   • Treat pain associated with spasticity
   • Manage withdrawal symptoms

2. Non-pharmacological approaches:

   • Sleep hygiene measures
   • Cognitive behavioral therapy for insomnia if available

3. Pharmacological options (with caution in ESRD):

   • Low-dose melatonin (0.5-3mg)
   • If necessary, consider short-term use of sleep medications with minimal renal elimination

Special Considerations for ESRD Patients

• Hemodialysis timing: If any medications with renal clearance are used, coordinate administration with hemodialysis schedule 2
• Toxicity risk: Even at low doses, baclofen can cause severe toxicity in ESRD patients 4, 5, 6
• Hemodialysis as treatment: Hemodialysis effectively removes baclofen and can be used therapeutically in cases of toxicity 7

Monitoring and Follow-up

• Regular assessment of spasticity, pain, and functional outcomes
• Monitor for side effects of any medications used
• Regular skin integrity assessment
• Adjust treatment based on response

Pitfalls and Caveats

• Never restart baclofen in this ESRD patient, as multiple studies demonstrate severe toxicity even at low doses in renal failure 4, 5, 6
• Abrupt discontinuation of baclofen can lead to withdrawal syndrome that may require intensive monitoring 2, 8
• Coordinate any medication regimen with the patient's dialysis schedule to prevent accumulation of metabolites 2
• Remember that treatment should focus on improving pain, skin hygiene, and function rather than just reducing muscle tone 2