In this episode, I’ll discuss a case report on the management of intrathecal baclofen withdrawal.
Managing a patient who is experiencing withdrawal from intrathecal baclofen can be incredibly challenging, especially if resuming the intrathecal baclofen is not an immediate option. A group of authors recently published in AJHP a case report on the use of dantrolene and cyproheptadine as salvage therapy for severe intrathecal baclofen withdrawal.
The case is that of a 51 year old male with a suspected intrathecal baclofen pump infection that necessitated the removal of the pump without immediate re-implantation. The patient had a 25+ year history of the use of the baclofen pump to treat spasticity from an old spinal cord injury.
Less than 24 hours after pump removal, the patient began to experience spasticity. This was treated with benzodiazepines however it continued to worsen and was followed by labile hemodynamics and tachycardia. Due to this, the patient was transferred to the ICU. The patient was intubated and treated with continuous infusions of midazolam and propofol. The patient developed SVT and hypotension which required a norepinephrine infusion. He became hyperthermic despite surface cooling and acetaminophen with a max temp just under 40 degrees celcius. A toxicologist was consulted who recemmoned dantrolene 1 mg/kg IV every 4 hours for 7 doses, for a total of 24 hours of therapy, and enteral cyproheptadine 8 mg every 6 hours. Enteral baclofen was also given at a dose of 40 mg every 6 hours. Over the next 4 days the patient’s condition improved, midazolam and propofol were weaned off, and by the 5th day cyproheptidine was also discontinued.
The authors concluded:
ITB withdrawal can be a life-threatening situation, and prompt and aggressive management is prudent to optimize outcomes for patients at high risk for ITB withdrawal syndrome. In our patient, despite enteral baclofen and high-dose IV GABA agents, the patient’s symptoms persisted. High-dose IV dantrolene and enteral cyproheptadine appeared to be well tolerated and improved our patient’s clinical status.
A pharmacist may only encounter this clinical problem once in a career, but having knowledge of these potential therapies can ensure they are started promptly to give the best chance of a successful outcome.
The article in this episode is a selection from my Hospital Pharmacy Academy’s weekly literature digest. Have you ever felt like your physician colleagues are one step ahead of you with new literature developments? Every week, Academy members are provided a summary curated and explained by me of the top hospital pharmacy-related articles published that week from over 20 major journals and sources to save you time and keep you up to date with the literature. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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