Should baclofen be stopped abruptly or gradually in a patient with End-Stage Renal Disease (ESRD) on dialysis?

Baclofen Discontinuation in ESRD Patients on Dialysis

Baclofen should be gradually tapered rather than stopped abruptly in patients with ESRD on dialysis to prevent potentially serious withdrawal symptoms including hallucinations and seizures. 1

Rationale for Gradual Tapering

Baclofen is primarily excreted unchanged through the kidneys, making patients with ESRD particularly susceptible to toxicity even at standard doses. The FDA drug label explicitly warns that "hallucinations and seizures have occurred on abrupt withdrawal of baclofen" and recommends that "except for serious adverse reactions, the dose should be reduced slowly when the drug is discontinued." 1

Risks of Baclofen in ESRD

• Baclofen accumulates in ESRD patients due to impaired renal clearance
• Multiple case reports document severe neurotoxicity in ESRD patients even with single doses:
  • Encephalopathy and altered mental status 2, 3
  • Delirium and visual hallucinations 4
  • Decreased muscle tone and hemodynamic instability 5

Discontinuation Protocol

For patients with ESRD on dialysis who need to stop baclofen:

1. Gradual taper schedule:

   • Reduce dose by 5-10mg every 3 days
   • If on higher doses, consider a slower taper with smaller increments
   • Continue until complete discontinuation

2. Monitor closely for withdrawal symptoms:

   • Hallucinations
   • Seizures
   • Increased muscle tone/spasticity
   • Agitation

3. Consider additional hemodialysis sessions:

   • If signs of toxicity are present, urgent hemodialysis can effectively reverse baclofen toxicity 2, 5
   • Multiple case reports show dramatic improvement after additional dialysis sessions 6, 3

Special Considerations

• If acute toxicity is present: The need for immediate discontinuation may outweigh the risk of withdrawal symptoms. In this case, intensive hemodialysis (2-3 sessions) should be used to rapidly clear the drug while managing withdrawal symptoms 2, 5

• Alternative medications: Consider alternative muscle relaxants with better safety profiles in ESRD after baclofen is discontinued

Prevention of Future Issues

Most experts recommend completely avoiding baclofen in patients with severely reduced kidney function (eGFR <30mL/min/1.73m²) or those on renal replacement therapy 5. Medication reconciliation is particularly important for ESRD patients to prevent similar medication-related problems in the future 7.

In conclusion, unless there is evidence of acute baclofen toxicity requiring immediate discontinuation and hemodialysis, the safest approach is a gradual taper to minimize the risk of withdrawal symptoms in your ESRD patient on dialysis.