Baclofen discontinuation

Abrupt discontinuation of intrathecal baclofen, regardless of the cause, has resulted in sequelae that include high fever, altered mental status, exaggerated rebound spasticity, and muscle rigidity, which in rare cases has advanced to rhabdomyolysis, multiple organ-system failure, and death. 

Prevention of abrupt discontinuation of intrathecal baclofen requires careful attention to programming and monitoring of the infusion system, refill scheduling and procedures, and pump alarms. Advise patients and caregivers of the importance of keeping scheduled refill visits and educate them on the early symptoms of baclofen withdrawal. Give special attention to patients at apparent risk (eg, spinal cord injuries at T-6 or above, communication difficulties, history of withdrawal symptoms from oral or intrathecal baclofen). Consult the technical manual of the implantable infusion system for additional postimplant clinician and patient information (see Warnings). 

Abrupt discontinuation of baclofen may produce hallucinations and seizures. 

A second major concern is the possibility that tolerance could develop with long-term, continuous baclofen administration. Tolerance is the need for more of a drug to achieve its beneficial effects when used for prolonged periods. Several studies have reported that dosage must indeed be increased progressively when intrathecal baclofen systems are used for periods of several months to several years.40,63 Tolerance to intrathecal baclofen, however, can usually be dealt with by periodic adjustments in dosage, and tolerance does not usually develop to such an extent that intrathecal baclofen must be discontinued. 

Common presenting features are muscular hyperactivity, hyperthermia, metabohc derangements, and rhabdomyo-lysis when baclofen therapy is abruptly discontinued, and several deaths have occurred (19). Qinicians should be suspicious of baclofen withdrawal if patients taking baclofen present with fever, muscle cramps, and hjrpotension. A case of brain death due to baclofen withdrawal with severe hypotension and hyperthermia up to 43 C has underscored the need for immediate and aggressive treatment (20). 

Baclofen must be tapered off when being discontinued. Abrupt withdrawal after prolonged use can cause anxiety, agitated behavior, hallucinations, severe tachycardia, acute spasticity, and seizures. 

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