Is it safe to continue dantrolene and Lunesta (eszopiclone) after a stroke?

Safety of Continuing Dantrolene and Lunesta After Stroke

Both dantrolene and Lunesta (eszopiclone) can generally be continued after stroke, but require careful monitoring and dose adjustments, with dantrolene being particularly useful for post-stroke spasticity and eszopiclone requiring reduced dosing in elderly or debilitated patients.

Dantrolene Safety and Use After Stroke

Evidence Supporting Continued Use

• Dantrolene is specifically indicated for treating spasticity following stroke and is FDA-approved for chronic disorders characterized by skeletal muscle spasticity, including stroke 1, 2.
• Clinical trials demonstrate that stroke patients with spasticity limiting rehabilitation experienced reduction in spasticity and clinical improvement after 6 weeks of dantrolene treatment, with 15 of 18 patients showing benefit 3.
• Long-term studies showed continuing benefit, with patients maintaining improvement on an average dose of 165.4 mg/day, and those switched to placebo experienced increased deficits 3.
• Dantrolene acts directly on skeletal muscle contractile mechanisms without affecting neural pathways, making it mechanistically appropriate for post-stroke spasticity management 2.

Critical Safety Considerations for Dantrolene

• Hepatotoxicity is the most serious concern, with potentially fatal hepatitis occurring in 0.1-0.2% of patients on long-term treatment 1, 2.
• Chemical evidence of liver dysfunction may occur in 0.7-1% of patients, with symptomatic hepatitis in 0.35-0.5% 2.
• Hepatitis can develop hours to days following use, though many cases occur in patients with comorbidities 1.
• Monitor liver function tests regularly during continued dantrolene therapy, particularly in the first 6 months 1.

Common Side Effects Requiring Monitoring

• Muscle weakness may be the principal limiting side-effect, particularly problematic in ambulant patients 2.
• Therapy could be hazardous in patients with pre-existing bulbar or respiratory weakness 2.
• Transient drowsiness, dizziness, weakness, general malaise, fatigue, and diarrhea commonly occur at therapy initiation 2.
• Loss of grip strength and leg weakness have been documented 1.

Dosing Recommendations Post-Stroke

• Individualize dosage based on patient response and tolerability 2.
• Typical dosing starts at 25mg once daily, increasing to 25mg two to four times daily, then by increments of 25mg up to 100mg two to four times daily 2.
• Use the lowest dose compatible with optimal response 2.

Eszopiclone (Lunesta) Safety After Stroke

Dose Adjustments Required

• The dose should not exceed 2 mg in elderly or debilitated patients, which includes many post-stroke patients 4.
• Downward dose adjustment is recommended when eszopiclone is administered with other CNS-depressant agents 4.
• Take immediately before bedtime to avoid short-term memory impairment, hallucinations, impaired coordination, dizziness, and lightheadedness 4.

Stroke-Specific Considerations

• Use with caution in patients with concomitant illness, as clinical experience in such patients is limited 4.
• Caution is advised if prescribed to patients with compromised respiratory function, which may be present after stroke 4.
• No dose adjustment appears necessary for renal impairment, as less than 10% is excreted unchanged in urine 4.

Behavioral and Cognitive Risks

• Complex behaviors such as "sleep-driving" have been reported, with increased risk when combined with alcohol or other CNS depressants 4.
• Discontinuation should be strongly considered if a sleep-driving episode occurs 4.
• Abnormal thinking and behavioral changes, including decreased inhibition, bizarre behavior, agitation, and hallucinations may occur 4.
• Amnesia and other neuropsychiatric symptoms may occur unpredictably 4.

Withdrawal Precautions

• Following rapid dose decrease or abrupt discontinuation, withdrawal symptoms similar to other CNS-depressant drugs have been reported 4.
• Gradual tapering is recommended if discontinuation is planned 4.

Monitoring Algorithm for Continued Use

For Dantrolene:

• Baseline and periodic liver function tests (AST, ALT, alkaline phosphatase, bilirubin) are essential 1, 2.
• Assess muscle strength regularly, particularly in ambulant patients 2.
• Monitor for respiratory function if any baseline compromise exists 2.
• Evaluate spasticity improvement using clinical assessments of disability and daily activities 2.

For Eszopiclone:

• Assess cognitive and motor performance, especially in elderly patients 4.
• Monitor for emergence of new behavioral signs or symptoms requiring immediate evaluation 4.
• Evaluate sleep quality and insomnia patterns; failure to remit after 7-10 days may indicate underlying psychiatric or medical illness 4.
• Screen for depression, as suicidal tendencies may be present and protective measures may be required 4.

Important Clinical Pitfalls to Avoid

• Do not use benzodiazepines (e.g., diazepam) during stroke recovery due to possible deleterious effects on recovery and sedation side effects 5, 6.
• Avoid combining eszopiclone with alcohol or other CNS depressants due to increased risk of complex behaviors 4.
• Do not abruptly discontinue either medication without appropriate tapering 4, 2.
• Be vigilant for hepatotoxicity with dantrolene, particularly in the first months of therapy 1, 2.
• Consider that muscle weakness from dantrolene may interfere with stroke rehabilitation efforts 2.