Management of Baclofen Withdrawal Symptoms
Immediately reinstitute baclofen therapy—this is the primary and most effective treatment for baclofen withdrawal, which can be life-threatening if not recognized and treated promptly. 1, 2
Recognition of Withdrawal Symptoms
Baclofen withdrawal presents with a constellation of symptoms that evolve over 1-3 days but may become fulminant without early intervention 1, 3:
Common Symptoms
- Visual and auditory hallucinations 1, 2
- Anxiety and agitation 1, 2
- Delirium 1, 2
- Rebound spasticity (often the earliest sign) 1
- Fever and tremors 2
- Tachycardia 2
- Seizures 2, 4
Severe Complications (Especially with Intrathecal Baclofen)
- High fever and altered mental status 1, 2
- Profound muscle rigidity leading to rhabdomyolysis 1, 2
- Multiorgan failure 1, 2
- Death 1, 2
Intrathecal baclofen withdrawal is particularly dangerous compared to oral formulations and requires heightened vigilance. 1
Primary Management Strategy
Step 1: Reinstitute Baclofen Immediately
- Restart baclofen therapy at the previous dose as soon as withdrawal is suspected—do not wait for confirmatory testing. 1, 2
- For intrathecal pumps, interrogate the pump immediately to identify malfunction or programming errors 5, 3
- Oral baclofen replacement is NOT effective for treating intrathecal baclofen withdrawal 5, 3
Step 2: Supportive Care and Bridging Therapy
While restoring baclofen therapy:
- Administer high-dose benzodiazepine infusions as life-saving bridging therapy 5, 3
- Start with midazolam 2 mg IV boluses, followed by infusion at 1 mg/h, titrating to effect 6
- Benzodiazepines provide GABAergic agonist activity to partially substitute for baclofen until it is reinstated 3
- Provide intensive care monitoring for hemodynamic instability, including bradyarrhythmias and hypotension 7
Step 3: Additional Supportive Measures
- Treat hyperthermia aggressively with cooling measures 5, 3
- Monitor for and manage rhabdomyolysis with aggressive fluid resuscitation 5, 3
- Dantrolene may relieve muscle rigidity but does NOT reverse other withdrawal manifestations 3
- Monitor renal function and treat acute kidney injury from rhabdomyolysis 5
Prevention Strategies
Never abruptly discontinue baclofen in patients on long-term therapy. 2, 4
Perioperative Management
- Continue baclofen therapy without interruption, including on the day of surgery 1, 2
- For intrathecal baclofen, obtain specialist consultation for perioperative management 2
When Discontinuation is Necessary
- Use gradual dose reduction over an extended period 1, 2, 4
- The FDA label specifically warns against abrupt withdrawal due to risk of hallucinations and seizures 4
Patient Education
- Educate patients and caregivers about withdrawal symptoms and the importance of medication adherence 5, 3
- Provide emergency contact information and backup medication supplies 3
- Schedule regular pump checks for patients with intrathecal systems 5
Critical Pitfalls to Avoid
Do not confuse baclofen withdrawal with baclofen toxicity—paradoxically, some autonomic features may overlap, making diagnosis challenging 8. Key distinguishing features:
- Withdrawal: hypertension, increased spasticity, hyperthermia, tachycardia 8, 3
- Toxicity: hypotension, muscle flaccidity, respiratory depression, bradycardia 8
Do not attempt to treat intrathecal baclofen withdrawal with oral baclofen—it is ineffective and delays appropriate therapy 5, 3.
Do not mistake withdrawal for other syndromes such as autonomic dysreflexia, malignant hyperthermia, neuroleptic malignant syndrome, or serotonin syndrome, though clinical overlap exists 3. The key differentiator is recent baclofen discontinuation or pump malfunction 3.
Special Populations
Neonatal Withdrawal
- Neonates born to mothers on chronic baclofen therapy may experience withdrawal symptoms hours to days after delivery 4
- Symptoms include increased muscle tone, tremor, jitteriness, and seizures 4
- Gradually reduce and discontinue baclofen before delivery when possible 4
Renal Impairment
- Exercise caution and reduce dosing in patients with impaired renal function, as baclofen is primarily renally excreted 4