What is the next step for an adult patient with a neurological condition and muscle spasticity who is currently taking baclofen (baclofen) 15 mg every 8 hours (q8hrs) without adequate relief?

Increase the Baclofen Dose

The next step is to increase the baclofen dose, as the current dose of 15 mg every 8 hours (45 mg/day total) is below the typical therapeutic range of 30-80 mg/day recommended for spasticity management. 1

Dosing Strategy

• Gradually titrate upward by 5-15 mg per day every 24-72 hours until adequate spasticity control is achieved or side effects limit further increases 1
• The typical therapeutic range is 30-80 mg/day divided into 3-4 doses, so there is substantial room for dose escalation from the current 45 mg/day 1
• Target the lowest effective dose that provides meaningful spasticity reduction while minimizing CNS adverse effects 2

Monitoring During Titration

• Assess the patient within 24 hours of each dose change for efficacy (reduction in muscle tone, spasms, pain) and tolerability (sedation, weakness, dizziness) 1, 3
• Monitor closely for muscle weakness, urinary function changes, cognitive effects, and sedation 4
• Be aware that baclofen may reduce spasticity and pain but produces no significant functional gains in stroke patients 2

Important Precautions

• Never abruptly discontinue baclofen, as this can cause potentially life-threatening CNS irritability and withdrawal syndrome with high fever, altered mental status, rebound spasticity, and muscle rigidity 1, 4
• Use with extreme caution in patients with compromised respiratory function, as baclofen can cause respiratory depression 1
• In patients with sleep-disordered breathing, carefully assess before escalating doses, as baclofen may worsen obstructive sleep apnea 2
• Older adults rarely tolerate doses greater than 30-40 mg per day, so titrate more cautiously in this population 4

Alternative Considerations if Maximum Oral Dose Fails

• For focal spasticity (e.g., hand, specific muscle groups): Consider botulinum toxin injections as first-line pharmacological treatment, which is more effective than baclofen for focal applications 1, 4
• For generalized spasticity unresponsive to oral baclofen at maximum tolerated doses (typically up to 80 mg/day): Consider intrathecal baclofen therapy, which requires only 10% of the systemic dose for equivalent effect and is indicated for severe refractory spasticity 1, 3, 5
• Alternative oral agents include tizanidine (starting 2 mg three times daily) or dantrolene for generalized spasticity if baclofen is ineffective or poorly tolerated 1, 4

Non-Pharmacological Adjuncts

• Ensure concurrent use of antispastic positioning, range of motion exercises, stretching, splinting, and appropriate physical therapy modalities, as these are first-line approaches that should complement pharmacological treatment 1, 2