How can I manage neuropathic pain and spasticity in a post‑stroke patient with flaccid hemiplegia who is currently taking baclofen 5 mg twice daily?

Management of Neuropathic Pain and Spasticity in Post-Stroke Flaccid Hemiplegia

For a post-stroke patient with flaccid hemiplegia on baclofen 5 mg BID experiencing neuropathic pain and spasms, you should add a gabapentinoid (pregabalin or gabapentin) as first-line therapy for the neuropathic pain component, while recognizing that baclofen has critical limitations in this specific population and may actually worsen function. 1, 2

Critical Understanding: Baclofen's Limited Role in Flaccid Hemiplegia

Baclofen is FDA-approved for spasticity from multiple sclerosis and spinal cord injuries, but its efficacy in stroke has not been established and is therefore not recommended for stroke patients. 3 This is a crucial distinction that many clinicians miss.

• Research specifically examining intrathecal baclofen in stroke patients with spastic hemiparesis found that 6 of 8 patients experienced functional deterioration because baclofen weakened their paretic side and suppressed the antigravity patterns they used for ambulation 4
• In flaccid hemiplegia specifically, baclofen provides minimal benefit since there is insufficient spasticity to treat, and the GABA-B agonist mechanism may further reduce already compromised motor control 2, 4
• The current 5 mg BID dose is subtherapeutic even for spasticity (typical range 30-80 mg/day divided into 3-4 doses), suggesting it's providing negligible antispasmodic effect 2, 5

First-Line Treatment: Add Gabapentinoids for Neuropathic Pain

Initiate pregabalin 25-50 mg daily or gabapentin 100-200 mg daily, titrating slowly given the post-stroke population. 1

Pregabalin (Preferred Option)

• Start 25-50 mg once daily at bedtime to minimize sedation 1
• Increase by 25-50 mg every 3-5 days as tolerated 1
• Target dose: 150-300 mg/day in two divided doses (morning and evening) 1
• Maximum dose: 600 mg/day if needed and tolerated 1, 6
• Pregabalin has more predictable pharmacokinetics and easier titration compared to gabapentin 1

Gabapentin (Alternative)

• Start 100-200 mg once daily at bedtime 1
• Increase by 100-200 mg every 3-5 days 1
• Target dose: 900-1800 mg/day in three divided doses 1
• Maximum dose: 3600 mg/day 1
• Requires slower titration due to saturable absorption 1

Both medications require dose reduction in renal impairment, which is common post-stroke. 1

Second-Line: Consider Antidepressants for Neuropathic Pain

If gabapentinoids provide inadequate relief or are not tolerated, add or switch to an antidepressant:

Duloxetine (Preferred SSNRI)

• Start 30 mg once daily for 1 week to reduce nausea 1
• Increase to 60 mg once daily (effective dose for neuropathic pain) 1
• Does not cause clinically significant ECG changes or blood pressure alterations 1
• Avoid in significant hepatic dysfunction 1

Nortriptyline or Desipramine (Preferred TCAs)

• Start 10-25 mg nightly 1
• Titrate to 50-75 mg nightly as tolerated 1
• Secondary amines (nortriptyline, desipramine) are better tolerated than tertiary amines (amitriptyline) with fewer anticholinergic effects 1
• Obtain screening ECG before initiating in patients over 40 years, limit dose to <100 mg/day, and use with extreme caution in ischemic cardiac disease 1
• Allow 6-8 weeks for adequate trial, including 2 weeks at maximum tolerated dose 1

Addressing the "Spasms" Component

The spasms in flaccid hemiplegia are likely painful muscle contractions related to neuropathic pain rather than true spasticity, making gabapentinoids and antidepressants more appropriate than increasing baclofen. 1, 2

• If true spasticity develops later (velocity-dependent increased tone), first-line non-pharmacological approaches include antispastic positioning, range of motion exercises, stretching, and splinting 2, 5
• For focal spasticity affecting specific muscle groups, botulinum toxin injections are superior to oral baclofen 2, 5
• Consider tapering and discontinuing baclofen if no clear benefit, but taper slowly over weeks to avoid withdrawal syndrome (never stop abruptly) 2

Topical Adjuncts for Localized Pain

If pain is localized to specific areas:

• Lidocaine 5% patch applied daily to painful areas (minimal systemic absorption) 1
• Can be used in combination with systemic gabapentinoids or antidepressants 1

Critical Pitfalls to Avoid

Do Not Increase Baclofen Dose

• Increasing baclofen in flaccid hemiplegia may worsen weakness and function without addressing neuropathic pain 2, 4
• Baclofen has minimal evidence for pain management outside spasticity-related conditions 2

Avoid Benzodiazepines

• Never use diazepam or other benzodiazepines during stroke recovery as they have deleterious effects on neurological recovery 2, 5, 7

Monitor for Sedation and Falls

• Post-stroke patients are at high risk for falls 1
• Start all medications at lowest doses and titrate slowly 1
• Gabapentinoids and antidepressants both cause dose-dependent sedation and dizziness 1

Renal Function Monitoring

• Both gabapentinoids require dose adjustment in renal impairment 1
• Check creatinine clearance before initiating and adjust doses accordingly 1

Treatment Algorithm

1. Add pregabalin 25-50 mg daily (or gabapentin 100-200 mg daily if pregabalin unavailable) 1
2. Titrate every 3-5 days to target dose of 150-300 mg/day pregabalin or 900-1800 mg/day gabapentin 1
3. Reassess pain at 2-4 weeks at target dose 1
4. If <30% pain reduction, add duloxetine 30 mg daily for 1 week, then 60 mg daily 1
5. If still inadequate, consider switching to nortriptyline 10-25 mg nightly (with ECG screening) 1
6. Consider tapering baclofen if no clear spasticity benefit, reducing by 5-10 mg every 1-2 weeks 2
7. Add lidocaine 5% patches for localized pain areas 1

Expected Timeline

• Gabapentinoids may show benefit within 1 week, but allow 4 weeks at target dose before declaring failure 1
• Antidepressants typically require 2-4 weeks for analgesic effect (earlier than antidepressant effect) 1
• TCAs require 6-8 weeks for adequate trial 1