From the Guidelines
Baclofen should be continued in older adults perioperatively, including the day of operation.
Considerations for Use
When using Baclofen in older adults, several factors must be taken into account, including:
- Potential for increased sedation: Baclofen can exacerbate sedation when used concomitantly with opiates and/or other central nervous system depressants, which is a concern in the perioperative period 1.
- Drug interactions: Baclofen is a muscle relaxant with a unique mechanism of action, and its interactions with other medications, including anesthetic agents, must be carefully considered.
- Comorbidity considerations: Older adults often have multiple comorbidities, and the use of Baclofen must be tailored to their individual needs and health status.
- Adverse drug effects: The potential for adverse effects, such as withdrawal symptoms, must be weighed against the benefits of continuing Baclofen perioperatively.
Perioperative Management
According to the Society for Perioperative Assessment and Quality Improvement (SPAQI) consensus statement, Baclofen should be taken preoperatively, including the day of operation 1. This recommendation is based on the available literature regarding the risks and benefits of Baclofen in the perioperative period.
From the FDA Drug Label
Because of the possibility of sedation, patients should be cautioned regarding the operation of automobiles or other dangerous machinery, and activities made hazardous by decreased alertness. Baclofen should be used with caution where spasticity is utilized to sustain upright posture and balance in locomotion or whenever spasticity is utilized to obtain increased function
The considerations for using Baclofen in older adults are not directly addressed in the provided drug labels. Key considerations that may be relevant to older adults, but are not explicitly stated as such, include:
- Caution with sedation and decreased alertness
- Caution with activities that require balance and locomotion However, these are general precautions and not specific to older adults. 2 2
From the Research
Considerations for Using Baclofen in Older Adults
- The use of baclofen in older adults is associated with a higher risk of fall compared to tizanidine, but the risk of fracture is similar among patients treated with baclofen, tizanidine, or cyclobenzaprine 3
- Baclofen is associated with encephalopathy, particularly in patients with chronic kidney disease or end-stage renal disease, and the risk of hospitalization for encephalopathy is increased in these patients 4
- The pharmacokinetics of high-dose baclofen may vary from those described previously, and time-to-peak plasma levels and plasma half-lives may be substantially longer than prior reports indicate 5
- Baclofen and tizanidine are associated with concerning adverse effects in older adults, including dyskinesias, encephalopathy, disorientation, drowsiness, bradycardia, and hypotension, and alternative agents should be considered 4
- Intrathecal baclofen may be associated with reduced spasm frequency and severity, as well as greater dose stability, compared to oral baclofen, but the risks of internal pump and catheter placement must be weighed against these benefits 6
- Baclofen is associated with a higher risk of injury and delirium compared to tizanidine when used for the treatment of musculoskeletal pain in older adults 7
Key Factors to Consider
- Age: older adults (aged 65 years or older) may be at increased risk of adverse effects from baclofen 3, 4, 7
- Renal function: patients with chronic kidney disease or end-stage renal disease may be at increased risk of encephalopathy from baclofen 4
- Dose: high-dose baclofen may be associated with increased risk of adverse effects, and alternative agents should be considered 5, 4
- Route of administration: intrathecal baclofen may be associated with reduced spasm frequency and severity, as well as greater dose stability, compared to oral baclofen 6