Baclofen Tapering Protocol
The recommended protocol for baclofen tapering is to reduce the dose by 5-10% of the original dose every 1-2 weeks, with larger initial reductions for high doses (>600 mg/day) and slower reductions for lower doses (<300 mg/day).
Tapering Schedule
Based on current daily dose, the following tapering schedule is recommended:
| Current Daily Dose | Recommended Taper |
|---|---|
| >600 mg/day | Reduce by 150 mg/day every 7 days until reaching 300 mg/day, then slow to 50-75 mg/day reductions |
| 300-600 mg/day | Reduce by 75 mg/day every 7 days |
| <300 mg/day | Reduce by 50 mg/day every 7 days |
For patients who experience significant withdrawal symptoms, a more gradual tapering approach may be necessary:
- 5% reduction every 2-4 weeks
- For very low doses (<100 mg), consider even smaller decrements (5-10 mg) at longer intervals
Withdrawal Symptom Management
Common baclofen withdrawal symptoms include:
- Anxiety, irritability, insomnia
- Tremor, diaphoresis, agitation
- Hypertension, tachycardia
- Hyperalgesia and myoclonus
These symptoms should be assessed before each dose reduction 1. In severe cases, withdrawal can lead to seizures, hallucinations, and psychosis.
The following medications may be used to manage specific withdrawal symptoms:
| Medication | Indication |
|---|---|
| Clonidine | Sympathetic hyperactivity |
| Loperamide | Gastrointestinal symptoms |
| Trazodone | Insomnia and anxiety |
| Hydroxyzine | Anxiety and agitation |
| Gabapentin | Insomnia and anxiety |
| Mirtazapine | Insomnia and anxiety |
| NSAIDs/Acetaminophen | Pain |
Special Populations
Elderly Patients
- More gradual tapering schedule (5% reduction every 2 weeks)
- Close monitoring for adverse effects
Patients with Hepatic/Renal Impairment
- Hepatic impairment: Initial dose reduced by 50% and tapered more gradually
- Renal impairment: Initial dose reduced by 25-50% with individualized tapering schedule
Patients with History of Seizures
- Require closer monitoring and slower tapering schedule
- Consider inpatient management if history of withdrawal seizures
Patient Monitoring
- Assess withdrawal symptoms before each dose reduction
- For outpatient management, provide clear written instructions about:
- Tapering schedule
- Signs and symptoms of withdrawal
- When to seek medical attention
- Emergency contact information
Important Considerations
- Abrupt discontinuation of baclofen can result in a potentially severe withdrawal syndrome 2
- For patients unable to take oral baclofen, intravenous baclofen may be considered as a bridge therapy with approximately 80% bioavailability (requiring a 20% dose reduction) 2
- For patients with severe dependence, the BRAVO Protocol (originally developed for opioids and benzodiazepines) provides a framework for extremely slow tapering, which may take several months 3
- In one documented case of severe gabapentin dependence, tapering required 18 months with dose reductions of 100 mg per month initially, slowing to 5 mg decrements every 1-2 weeks for the final 100 mg 3
Adjunctive Therapies
- Cognitive behavioral therapy significantly increases tapering success rates
- Non-pharmacological approaches that may help manage withdrawal symptoms:
- Regular exercise
- Sleep hygiene practices
- Stress management techniques
By following this structured approach to baclofen tapering, the risk of withdrawal symptoms can be minimized while safely discontinuing the medication.