use benzodiazepine for baclofen withdrawal

In addition to severe sepsis arising from the migration of the baclofen pump, this patient is likely experiencing baclofen withdrawal, and the administration of a benzodiazepine, such as lorazepam, titrated against the spasms, is a recommended treatment. Baclofen is structurally similar to γ-aminobutyric acid (GABA), an inhibitory neurotransmitter widely acting throughout the central nervous system (CNS). Baclofen reduces muscle spasticity by acting on the spinal cord. Since oral administration results in actions throughout the CNS, control of spasticity with baclofen often results in excessive sedation, as in this patient. This undesirable side effect can be obviated by administration of baclofen directly into the intrathecal space. Surgically implanted computer-programmed refillable pumps are increasingly used to treat the severe spasms that can occur in cerebral palsy, multiple sclerosis, cord injury, and other neurologic disorders. It is not unusual for the clinician to encounter patients with these implanted devices in the ICU.

When baclofen has been administered orally or by pump and is abruptly discontinued, a severe withdrawal syndrome can evolve over hours to a few days, characterized by severe muscle spasms, delirium, fever, and rhabdomyolysis. Multisystem organ failure and death have been described, and sudden discontinuation of intrathecal administration often causes more severe withdrawal than cessation of oral baclofen.

Treatment of withdrawal is often simply restoring baclofen dosing, but that is not likely to occur in a reasonable time frame for this patient. The current implanted device requires removal, and replacement cannot occur until the issue of infection has been resolved. The patient is early on in a course of sepsis with nausea and vomiting, and oral baclofen is not feasible. In this setting, a benzodiazepine medication would be a first-choice treatment, given the GABA-agonist actions of these drugs. Lorazepam would be a good choice, given its time to onset of action and duration. Some clinicians prefer diazepam because of its longer half-life.

While the benzodiazepines are not first-line treatments for many sedation needs in the ICU, they are excellent choices for several withdrawal states, including baclofen withdrawal. If patients progress despite titration of a benzodiazepine to their symptoms and especially if intubation is required, propofol is another useful sedative for this condition.

Flumazenil is a GABA-antagonist developed to counter the action of the benzodiazepines. Flumazenil would worsen baclofen withdrawal and would be contraindicated in this patient. Naloxone blocks the action of opiates and would have no role in baclofen withdrawal. Hydromorphone is an opiate with side effects of muscle spasm and would be contraindicated in this patient.12345

Footnotes

  1. SEEK Questionnaires ↩

  2. Alden TD, Lytle RA, Park TS, et al. Intrathecal baclofen withdrawal: a case report and review of the literature. Childs Nerv Syst. 2002;18(9-10):522-525. PubMed ↩

  3. Romito JW, Turner ER, Rosener JA, et al. Baclofen therapeutics, toxicity, and withdrawal: a narrative review. SAGE Open Med. 2021;9:20503121211022197. PubMed ↩

  4. Saulino M, Anderson DJ, Doble J, et al. Best practices for intrathecal baclofen therapy: troubleshooting. Neuromodulation. 2016;19(6):632-641. PubMed ↩

  5. Schmitz NS, Krach LE, Coles LD, et al. Characterizing baclofen withdrawal: a national survey of physician experience. Pediatr Neurol. 2021;122:106-109. PubMed ↩