What is the best muscle relaxer for a 66-year-old male?

Best Muscle Relaxer for a 66-Year-Old Male

For a 66-year-old male, baclofen is the preferred muscle relaxant, starting at 5 mg up to three times daily with a maximum tolerated dose of 30-40 mg per day, as it has the most favorable safety profile in elderly patients. 1, 2

Primary Recommendation: Baclofen

• Baclofen is specifically recommended by the American Geriatrics Society as the preferred muscle relaxant for elderly patients due to its documented efficacy and relatively safer profile compared to other agents 1, 2
• Start with 5 mg up to three times daily, with older persons rarely tolerating doses greater than 30-40 mg per day 1, 2
• Baclofen functions as a gamma amino butyric acid type B agonist with documented efficacy as a second-line drug for paroxysmal neuropathic pain and in patients with severe spasticity from CNS injury 2
• Critical pitfall: Never abruptly discontinue baclofen due to risk of withdrawal symptoms including CNS irritability 1

Alternative Option: Tizanidine

• Tizanidine is the recommended alternative if baclofen is not tolerated, starting at 2 mg up to three times daily 1, 2
• Use with extreme caution in renally impaired patients, which is common at age 66 1, 2
• Monitor closely for orthostatic hypotension, sedation, and potential drug-drug interactions 1
• Titrate the dose slowly while monitoring for side effects 1

Muscle Relaxants to Absolutely Avoid in This Age Group

• Cyclobenzaprine should be avoided as it is structurally identical to tricyclic antidepressants with comparable adverse effects including CNS impairment, delirium, slowed comprehension, and falling 1, 2
• Carisoprodol should be completely avoided due to high risk of sedation, falls, and potential for physical and psychological dependence 2, 3
• Orphenadrine is listed in the Beers Criteria as potentially inappropriate due to strong anticholinergic properties that can cause confusion, anxiety, tremors, urinary retention, and cardiovascular instability 1, 2
• Methocarbamol has significantly impaired elimination in patients with liver and kidney disease and causes drowsiness, dizziness, bradycardia, and hypotension 1, 2
• Metaxalone is contraindicated in patients with significant hepatic or renal dysfunction 1, 2

Critical Safety Considerations

• All muscle relaxants are listed in the American Geriatrics Society Beers Criteria as potentially inappropriate medications for older adults due to anticholinergic effects, sedation, and increased risk of falls 1, 2
• Start with the lowest possible effective dose and use for the shortest duration necessary 1, 2
• Avoid prescribing muscle relaxants with other medications that have anticholinergic properties 1, 2
• Most muscle relaxants have limited evidence of efficacy for chronic pain management in elderly patients 1, 2

Evidence Quality Note

While skeletal muscle relaxants show efficacy for acute low back pain with short-term pain relief after 2-4 days and 5-7 days compared to placebo 4, the evidence is insufficient for chronic low back pain 4. The guideline recommendations prioritize safety in the elderly population over pure efficacy data, which is appropriate given the significant fall risk and other adverse effects in this age group 1, 2.