What are the next steps if baclofen (baclofen) is not effective in managing muscle tone?

Management of Muscle Tone When Baclofen is Ineffective

When baclofen is not effective in managing muscle tone, the next step should be to consider botulinum toxin injections for focal spasticity or intrathecal baclofen for generalized spasticity that has not responded to oral medications. 1, 2

Alternative Pharmacological Options

• Tizanidine or dantrolene can be considered as alternative oral agents for generalized spasticity when baclofen is ineffective 1
• Gabapentinoids (pregabalin, gabapentin) are recommended as first-line adjuvant analgesics for neuropathic pain that may accompany spasticity 1
• Orphenadrine and methocarbamol have been proposed for muscle cramps in patients with cirrhosis when baclofen is ineffective 3
• Quinidine at 400 mg/day for 4 weeks has shown effectiveness against painful muscle cramps, though toxicities like diarrhea may limit its use 3

Non-Pharmacological Approaches

• First-line approaches should include antispastic positioning, range of motion exercises, stretching, splinting, and serial casting 1
• Physical therapy modalities, functional electrical stimulation, and transcutaneous electrical nerve stimulation may improve upper-extremity motor outcomes 1
• For patients with tense ascites and muscle cramps, human albumin solution (20-40 g/week) may be considered 3

Botulinum Toxin for Focal Spasticity

• Botulinum toxin is recommended for focal spasticity and has been shown to be more effective than baclofen for certain applications 1, 2
• Targeted injection of botulinum toxin into localized muscles can reduce spasticity that interferes with function 2
• A small RCT found botulinum toxin superior to oral baclofen for ankle spasticity 1

Intrathecal Baclofen for Severe Spasticity

• Intrathecal baclofen is indicated for patients with severe spastic hypertonia unresponsive to maximum doses of oral baclofen 1, 4
• Studies show >80% of patients have improvement in muscle tone and >65% have improvement in spasms with intrathecal baclofen 1
• Intrathecal baclofen delivers the medication directly to the cerebrospinal fluid at concentrations less than one-hundredth of those used orally, minimizing systemic side effects 5
• Advantages include programmable continuous infusion that allows fine titration of doses throughout the day 5
• Level 2 evidence supports the effectiveness of intrathecal baclofen infusion for short-term reduction of severe spasticity in patients unresponsive to oral baclofen 5

Treatment Algorithm

1. Confirm failure of oral baclofen therapy (typically dosed 30-80 mg/day divided into 3-4 doses) 1
2. For generalized spasticity:
   • Try alternative oral agents: tizanidine or dantrolene 1
   • If still ineffective, consider intrathecal baclofen pump 1, 4, 6
3. For focal spasticity:
   • Botulinum toxin injections to affected muscles 1, 2
4. For severe, refractory spasticity:
   • Intrathecal baclofen pump implantation 4, 7, 5
   • Neurosurgical procedures (selective dorsal rhizotomy or dorsal root entry zone lesion) as last resort options 1

Important Considerations and Precautions

• Avoid benzodiazepines during stroke recovery due to potential negative effects on recovery 1
• Baclofen may worsen obstructive sleep apnea by promoting upper airway collapse during sleep 1, 8
• Intrathecal baclofen requires careful patient assessment, selection, and continued monitoring to prevent complications from overdose or withdrawal 4, 9
• Patients with chronic kidney disease generally require higher doses of loop diuretics and lower doses of aldosterone antagonists when managing muscle tone issues related to ascites 3