From the Guidelines
For a patient with multiple sclerosis experiencing a flare while on tizanidine 4mg every 8 hours, the next step should be initiating a short course of high-dose corticosteroids, typically methylprednisolone 1000mg IV daily for 3-5 days, followed by an oral prednisone taper. This approach helps reduce inflammation and shortens the duration of the flare, as evidenced by clinical practice guidelines for managing multiple sclerosis exacerbations. The patient should be evaluated by their neurologist promptly to assess the severity of the flare and potentially adjust their disease-modifying therapy. Continue the tizanidine for symptom management of spasticity, but consider increasing to 6mg every 8 hours if spasticity remains problematic (maximum 36mg daily) as per the management of adult stroke rehabilitation care guideline 1. Monitor for side effects including sedation, dry mouth, and hypotension. Additionally, ensure the patient has adequate rest, maintains hydration, and avoids triggers like heat exposure that can worsen symptoms. Physical therapy may be beneficial during recovery to maintain function. If symptoms don't improve within 1-2 weeks of corticosteroid treatment, a follow-up MRI may be needed to evaluate for new lesions or alternative causes of symptom worsening, following the evidence-based guidelines for the use of MRI in multiple sclerosis 1. Key considerations include:
- Initiating high-dose corticosteroids to reduce inflammation
- Evaluating the patient's disease-modifying therapy
- Managing spasticity with tizanidine
- Monitoring for side effects
- Maintaining function with physical therapy
- Considering follow-up MRI if symptoms persist.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION A single oral dose of 8 mg of tizanidine reduces muscle tone in patients with spasticity for a period of several hours. The effect peaks at approximately 1 to 2 hours and dissipates between 3 to 6 hours. Effects are dose-related Although single doses of less than 8 mg have not been demonstrated to be effective in controlled clinical studies, the dose-related nature of tizanidine’s common adverse events make it prudent to begin treatment with single oral doses of 4 mg. Increase the dose gradually (2 mg to 4 mg steps) to optimum effect (satisfactory reduction of muscle tone at a tolerated dose) The dose can be repeated at 6 to 8 hour intervals, as needed, to a maximum of three doses in 24 hours. The patient is currently on tizanidine 4mg every 8 hours. Next steps could be to:
- Increase the dose gradually (2 mg to 4 mg steps) to optimum effect, as the current dose may not be sufficient to control the patient's spasticity.
- Consider increasing the frequency of dosing, as the dose can be repeated at 6 to 8 hour intervals, as needed, to a maximum of three doses in 24 hours 2.
From the Research
Current Treatment and Next Steps
The patient is currently on tizanidine 4mg every 8 hours for spasticity associated with multiple sclerosis (MS) 3.
Assessment of Current Treatment
Tizanidine has been shown to reduce clinical spasticity and hyperreflexia in MS patients, although it may not change functional status 3.
Alternative and Additional Treatment Options
Other treatment options for spasticity in MS include:
- Therapeutic exercise
- Physical modalities
- Complementary/alternative medicine interventions
- Oral medications
- Chemodenervation
- Implantation of an intrathecal baclofen pump 4
- Skilled rehabilitation strategies
- Neuromuscular blocks
- Intrathecal management
- Surgery 5
Management of MS Relapses
For MS relapses, high-dose short-term oral or intravenous methylprednisolone for 3-5 days can speed up recovery, but it has no influence on the occurrence of new relapses or long-term disability 6.
Disease-Modifying Therapies
There are nine classes of disease-modifying therapies (DMTs) available for relapsing-remitting MS and secondary progressive MS with activity, which can reduce clinical relapses and MRI lesions 7.
Considerations for Next Steps
The next steps in management may involve:
- Adjusting the current dose of tizanidine or switching to an alternative oral medication
- Considering other treatment options for spasticity, such as chemodenervation or intrathecal baclofen pump
- Evaluating the need for disease-modifying therapies to reduce relapses and slow disease progression
- Referral to a MS Center with a spasticity program for further evaluation and management 5