Baclofen Dosing for Adults
For general spasticity management, start baclofen at 5 mg three times daily and titrate upward every 3 days (5 mg TID → 10 mg TID → 15 mg TID → 20 mg TID), with a typical effective dose range of 40-80 mg daily and a maximum of 80 mg daily. 1
Standard Dosing Protocol
The FDA-approved titration schedule provides a structured approach 1:
- Days 1-3: 5 mg three times daily (15 mg/day total)
- Days 4-6: 10 mg three times daily (30 mg/day total)
- Days 7-9: 15 mg three times daily (45 mg/day total)
- Days 10-12: 20 mg three times daily (60 mg/day total)
- Beyond day 12: Further increases may be made, but do not exceed 80 mg daily (20 mg four times daily) 1
The lowest dose compatible with optimal response should be used. 1 If benefits are not evident after a reasonable trial period, slowly withdraw the medication rather than abruptly discontinuing. 1
Special Population Dosing
Elderly Patients
Older adults require significantly lower doses and slower titration. 2 The American Geriatrics Society specifically notes that elderly patients rarely tolerate doses greater than 30-40 mg per day. 2 Start at 5 mg up to three times daily with careful monitoring for muscle weakness, urinary dysfunction, cognitive effects, and sedation. 2
Alcohol Use Disorder with Liver Disease
For alcohol abstinence maintenance in patients with liver disease, use 30-60 mg daily (typically 10 mg three times daily). 2 This dosing was validated in a randomized trial showing improved abstinence rates in patients with both compensated and decompensated cirrhosis over 12 weeks. 2
Important caveat: Patients with hepatic encephalopathy were excluded from these trials, as baclofen may impair mentation—a side effect potentially exacerbated in advanced liver disease. 2
Muscle Cramps in Cirrhosis
For cirrhosis-related muscle cramps, start at 10 mg daily and increase weekly by 10 mg increments up to 30 mg daily. 3 This represents a more gradual titration appropriate for patients with severe liver disease. 2
Renal Impairment Considerations
Dose adjustment is required in renal impairment, as baclofen blood levels may accumulate over time. 3 Baclofen is primarily renally excreted, necessitating careful monitoring and potential dose reduction in patients with decreased kidney function.
Critical Safety Warnings
Abrupt Discontinuation
Never abruptly discontinue baclofen due to risk of central nervous system irritability and potentially severe withdrawal syndrome. 2, 1 Always taper slowly when discontinuing therapy.
Monitoring Parameters
Monitor closely for 2:
- Muscle weakness (may impair mobility and transfers)
- Urinary dysfunction (retention or incontinence)
- Cognitive effects (confusion, memory impairment)
- Sedation (dose-related, typically at doses >60 mg/day)
Alternative Formulations
Once-daily sustained-release (SR) or gastric-retentive system (GRS) formulations at the same total daily dose are acceptable alternatives to three-times-daily immediate-release baclofen. 4 These formulations provide equivalent efficacy with potentially better tolerability and compliance, showing significant reductions in sedation scores compared to immediate-release formulations. 4
Clinical Pearls
- Bioavailability is approximately 80% for oral baclofen, which is relevant if considering IV bridging therapy when oral administration is interrupted. 5
- Response assessment should occur within 24 hours of any dose change. 6
- Sedation and other adverse effects are dose-related, typically appearing at doses >60 mg/day. 7
- For dystonia, higher doses (40-180 mg daily) have been used in children and adolescents with variable success, though adult response to baclofen for focal dystonia is less dramatic. 8