From the Guidelines
Refractory muscle cramps can be effectively treated with baclofen, starting at a dose of 10 mg/day, with a weekly increase of 10 mg/day up to 30 mg/day, as recommended by the most recent and highest quality study 1. This approach is based on the latest guidance from the American Association for the Study of Liver Diseases, which suggests that baclofen can help alleviate muscle cramps in patients with liver disease, particularly those on diuretic treatment for ascites. Key considerations for treatment include:
- Correction of electrolyte alterations, such as hypokalemia and hypomagnesemia, which can contribute to muscle cramps
- Use of albumin infusion, which may also help alleviate muscle cramps
- Avoidance of medications that can exacerbate muscle cramps, such as certain diuretics
- Monitoring for adverse effects of treatment, such as diarrhea with quinidine use The European Association for the Study of the Liver also recommends albumin infusion or baclofen administration for patients with muscle cramps 1. It is essential to tailor treatment to the underlying cause of muscle cramps and to consult with a healthcare provider for proper diagnosis and management. Other medications, such as orphenadrine and methocarbamol, have been proposed for muscle cramps in patients with cirrhosis, but baclofen is the most recently recommended and highest quality option 1.
From the FDA Drug Label
Theophylline or aminophylline No change in the quinine sulfate capsules dosage regimen is necessary with concomitant theophylline or aminophylline [see Clinical Pharmacology (12. 3)] . Astemizole (CYP3A4 substrate) Elevated plasma astemizole concentrations were reported in a subject who experienced torsades de pointes after receiving three doses of quinine sulfate for nocturnal leg cramps concomitantly with chronic astemizole 10 mg/day.
The treatment for refractory muscle cramps may include quinine sulfate capsules, as it is mentioned that quinine sulfate was used for nocturnal leg cramps 2. However, it is crucial to monitor patients closely for adverse reactions associated with quinine.
- Key considerations for using quinine sulfate capsules include:
- Avoiding concomitant administration with certain medications, such as macrolide antibiotics, rifampin, and ritonavir
- Monitoring plasma concentrations of other drugs that may interact with quinine
- Adjusting doses of other medications as necessary to minimize the risk of adverse reactions
- Closely monitoring patients for signs of muscle pain, tenderness, or weakness, particularly during initial therapy.
From the Research
Treatment Options for Refractory Muscle Cramps
- The treatment of muscle cramps involves determining if there is an underlying cause and using physical measures such as stretching 3.
- Pharmacologic treatments have a moderate interest due to potential toxicity or limited effectiveness, with options including quinine sulfate, vitamin B complex, naftidrofuryl, and calcium channel blockers such as diltiazem 3, 4.
- Magnesium supplements are marketed for the prophylaxis of cramps, but the efficacy of magnesium for this purpose remains unclear, with studies showing conflicting results 5, 6, 7.
- For idiopathic cramps, magnesium supplementation is unlikely to provide clinically meaningful cramp prophylaxis to older adults experiencing skeletal muscle cramps 6, 7.
- In contrast, for those experiencing pregnancy-associated rest cramps, the literature is conflicting and further research in this population is needed 6, 7.
Considerations for Treatment
- Quinine derivatives may be effective for treating muscle cramps, but their use is cautioned due to potential toxicity, and they should only be considered for select patients after weighing potential side effects 4.
- Vitamin B complex, naftidrofuryl, and calcium channel blockers such as diltiazem are possibly effective and may be considered in the management of muscle cramps 4.
- Further studies are needed to identify agents that are effective and safe for the treatment of muscle cramps 4.