What is the starting dose of baclofen for an adult patient with muscle spasticity?

Starting Dose for Baclofen

For adult patients with muscle spasticity, start baclofen at 5 mg three times daily (total 15 mg/day), then titrate gradually every 3-7 days based on response and tolerability. 1

Standard Adult Dosing Protocol

• Initial dose: 5-10 mg three times daily is the recommended starting regimen, with most guidelines favoring the lower end of this range (5 mg TID) to minimize side effects 1
• Titration schedule: Increase gradually to reach a typical effective total daily dose of 30-60 mg/day, though this should be adjusted based on patient response 1
• The standard therapeutic range is 15-60 mg per day, with most patients responding adequately in the 30-60 mg range 1

Special Population Adjustments

Elderly Patients (≥65 years)

• Start lower and go slower: Begin at 5 mg twice daily (not three times daily) due to increased sensitivity to side effects 1, 2
• Increase by 5 mg increments every 5-7 days rather than every 3 days 1
• Elderly patients rarely tolerate doses greater than 30-40 mg per day 2
• Monitor closely for muscle weakness, urinary dysfunction, cognitive impairment, and sedation 3, 2

Patients with Renal Impairment

• Dose reduction is required as baclofen is primarily renally excreted 1, 2
• Blood levels may accumulate over time, necessitating careful monitoring and potential dose adjustments 2, 4

Patients with Liver Disease

• For muscle cramps in cirrhosis: Start at 10 mg daily and increase by 10 mg weekly up to 30 mg daily 1, 3, 2
• This represents a more gradual titration appropriate for severe liver disease 2
• Exclude patients with hepatic encephalopathy, as baclofen may worsen mentation 2

Indication-Specific Considerations

Muscle Spasticity (Primary Indication)

• Standard dosing applies: 5-10 mg three times daily initially 1
• Titrate to effect, typically reaching 30-60 mg/day 1

Alcohol Use Disorder

• Target maintenance dose is 30 mg daily (10 mg three times daily) 3, 2
• Can be prescribed up to 80 mg/day per marketing authorization 1

Neuropathic Pain (Adjunctive)

• Lower doses may suffice when combined with other analgesics 1
• Standard starting dose still applies, but final dose may be lower than for spasticity 1

Critical Safety Monitoring

Common Side Effects to Monitor

• Sedation, drowsiness, and dizziness are dose-dependent 1
• Muscle weakness (paradoxical in spasticity treatment) 1, 3
• Cognitive impairment, particularly in elderly 1, 2
• Urinary dysfunction 1, 2

Important Pitfall: Abrupt Discontinuation

• Never stop baclofen abruptly after prolonged use—this can cause CNS irritability and potentially severe withdrawal syndrome 1, 3, 2
• Always taper slowly when discontinuing therapy 3, 2

Paradoxical Worsening

• Some patients may experience worsening spasticity with dose increases 5
• If symptoms worsen with titration, consider decreasing rather than increasing the dose 5

Practical Titration Algorithm

1. Week 1: Start 5 mg three times daily (or 5 mg twice daily if elderly) 1, 2
2. Week 2: If tolerated, increase to 10 mg three times daily 1
3. Weeks 3-6: Continue increasing by 5-10 mg increments every 3-7 days until reaching therapeutic effect or 60 mg/day 1
4. Maintenance: Most patients respond at 30-60 mg/day total 1
5. Monitor: Assess for efficacy and side effects at each dose change 1