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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 2  |  Page : 190-191

A case of baclofen induced myoclonus


1 Assistant Professor, Dept. of Neurology, NMCH, Patna, Bihar, India
2 Associate Professor, Neurology, IGIMS, Patna, Bihar, India
3 Junior Resident, Dept. of Medicine, NMCH, Patna, Bihar, India

Date of Submission13-Feb-2019
Date of Acceptance20-Jul-2019
Date of Web Publication12-Aug-2019

Correspondence Address:
Anwar Alam
Assistant professor, Department Of Neurology, NMCH, Patna
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 


Baclofen is known to cause neurotoxicity in patients with renal dysfunction. Here Authors reported a case of rapidly developed Myoclonus after few doses of Baclofen. These symptoms were abated after stopping Baclofen. Authors concluded that, in patients who developed sudden onset Myoclonus, drug history should be reviewed in detail, and Baclofen toxicity {especially in patients with end stage renal disease (ESRD)} should be kept in mind along with drugs which are known to cause the Myoclonus.

Keywords: Baclofen, Myoclonus, ESRD


How to cite this article:
Alam A, Ranjan A, Kumar B, Rajalakshmi C. A case of baclofen induced myoclonus. J Indira Gandhi Inst Med Sci 2019;5:190-1

How to cite this URL:
Alam A, Ranjan A, Kumar B, Rajalakshmi C. A case of baclofen induced myoclonus. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2023 Feb 5];5:190-1. Available from: http://www.jigims.co.in/text.asp?2019/5/2/190/301112




  Introduction : Top


Baclofen, an analogue of g-aminobutyric acid(GABA) is a centrally acting GABA agonist. It has been commonly used to treat muscle spasms associated with various neurologic conditions, including spinal injury, Multiple sclerosis as well as neuroleptic-induced tardive dyskinesias and control of intractable hiccups[1]. Exact mechanism of action of Baclofen is not fully known till date but it can hyperpolarize the afferent terminals which ultimately inhibit polysynaptic and monosynaptic reflexes at the spinal level [2],[3],[4]. The usual dose ranges from 10 to 200 mg/day. Baclofen is generally well tolerated, but adverse effects are not uncommon, especially when higher doses are used or when it has been used in patients with renal failure. Baclofen is lipophilic, 30% of it is protein bound and it can cross blood brain barrier. There is large variation in absorption and elimination, but it is rapidly and extensively absorbed and excreted mainly by kidney(70-85%), rest 15 % eliminated in inactive form by liver[2],[5].


  Case : Top


A 70 yr old male, a known case of hypertension and chronic kidney disease for last 4 years presented with complaints of generalized weakness, loss of appetite, fever ( mild grade) with chills and rigor and non productive cough for last 10 days.

On examination, pallor, icterus, cyanosis, lymphadenopathy and edema were absent. Vitals were stable. On chest auscultation, there were bilateral crepitations. Cardiovascular examination was normal.

On central nervous system examination he was conscious but drowsy, followed commands after repetition and there was no focal neurological deficit. His initial laboratory parameters were Hb 9.5gm%, TLC 5,800/mm3, DLC P72%, L20%, E05%, B03%, Blood urea 52.12 mg/dl, S.Creatinine 2.31 mg/dl ,Total Bilirubin 0.68 mg/dl, Direct 0.25 mg/dl, Indirect 0.43 mg/dl, SGOT 69.84 U, SGPT61.11U, ALP 313 IU and Total protein 6.86 g/dl, S.Sodium was 118 meq/dl, S. Potassium was 4.8 meq/dl.

Diagnosis of HTN/ CKD/ Hyponatremia/ LRTI were made. Antibiotics were added and he was put on infusion (3% NaCl) as he was drowsy.
Figure 1: CT Scan head showing diffuse cerebral atrophy along with periventricular ischemic changes

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On the day of admission, he developed recurrent hiccups for which he was given Baclofen 10mg TDS, but after second dose of Baclofen it was observed that he developed frequent blepharospasm with frequent jaw opening movement, and he also developed restlessness.


  Discussion : Top


After reviewing the literature, very few case reports regarding neurological side effects of Baclofen were found and more so, not a single report to the best of authors’ knowledge on Myoclonus as side effect. In patients with normal renal function, drowsiness, dizziness, fatigue, sedation, coma and respiratory depression are known side effects. But, they are with higher doses of Baclofen and most of the serious side effects are reported with intrathecal Baclofen.[6],[7]

In this case, side effects like intermittent blepharospasm and in between jaw opening myoclonic movements were observed in the patient. And these occured only after gettng 20 mg of Baclofen which was given for control of hiccups.

In patients with impaired renal function and ESRD, the half life of Baclofen is significantly increased (70-85% excreted by kidney). So even a small daily dose(5mg) of Baclofen or cumulative dose 15 mg can cause rapid accumulation and severe intoxication. Even respiratory depression and coma can also develop rapidly after initiation of therapy. In our case, the symptoms were completely abated after withdrawal of Baclofen.

S S Beladi Mousavi et al[8] reported two cases of Baclofen induced encephalopathy and both of th em required hemodialysis. Their symptoms improved over 3-4 days. In our case the recovery took 72 hours.

Baclofen induced encephalopathy was also reported previously by Chu Lin et al[9] in which he reported two patients with CKD who rapidly developed altered sensorium, when it was given for intractable hiccups. His second patient needed hemodialysis after stopping the drug and he recovered completely. In our patient, mere cessation of drug resulted complete improvement.


  Conclusion : Top


In patients who develop sudden onset myoclonus, drug history should be reviewed in detail, and Baclofen toxicity (especially in patients with ESRD) should be kept in mind along with drugs which are already known to cause myoclonus.



 
  References Top

1.
Standaert DG, Young AB. Treatment of central nervous system degenerative disorders. In: Brunton LL, Lazo JS, Parker KL, eds. Goodman and Gilman’s the pharmacological basis of therapeutics. 12th ed. Columbus, OH: McGraw-Hill Publishers, 2005:543.  Back to cited text no. 1
    
2.
Wuis EW,Dirks MJ,,Termond EF ,Vree TB, Vander Klein E:Plasma and urinary excretion kinetics of oral baclofen in healthy subjects . Eur J Clin Pharmacology 1989;37:181-4  Back to cited text no. 2
    
3.
Dario A,Tomei G, A benefit risk assessment of baclofen in severe spinal spasticity.Drug Sat2004;27:799-818  Back to cited text no. 3
    
4.
Flardh M ,Jacobson BM,Sensitive method for the determination of baclofen in plasma by means of Solid phase extraction and liquid chromatography-tandem mass spectrometry. J Chromatogra 1999;846:169-73  Back to cited text no. 4
    
5.
Choo YM,Kim GB ,ChoiJY,Park JH, Yang CWet al severe respiratory depression by low dose baclofen in the treatment of chronic hiccups in a patient undergoing CAPD.Nephron 2000;86:546-7  Back to cited text no. 5
    
6.
Bassilos N,Launay- Vacher V,Mercadal L,Deray G Baclofen neurotoxicity in a chronic hemodialysis patient .Nephrology Dialysis Transplant 2000;15:715-6  Back to cited text no. 6
    
7.
Chen KS ,Bullard MJ, Chein YY,Lee SY: Baclofen toxicity in patients with severly impaired renal function Ann Phamaco therapy 1997 ;31:1315-20  Back to cited text no. 7
    
8.
Beladi Mousavi SS, Beladi Mousavi M, F Motemednia .Baclofen- induced encephalopathy in patients with end stage renal disease:Two case reports: Indian journal of nephrology 2012 ;22:210-2  Back to cited text no. 8
    
9.
Chou CL,Chen CA , Lin SH,Huang HH. Baclofen-induced neurotoxicity in chronic renal failure patients with intractable hiccups Suoth Med J 2006;99:1308-9  Back to cited text no. 9
    


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