Where possible seek specialist advice from a Rehabilitation Consultant or Consultant Neurologist, especially if:
- Spasticity is localised to a limited muscle group which would be better managed using focally active medications.
- Patient has a limited response to first line medications.
Having addressed any aggravating factors, the most commonly used medicines in typical order of preference are:
- Baclofen: This should be commenced at 5mg three times daily and increasing in 5mg three times daily weekly increments to maximum of 100mg per day. Sedation is a common side effect, but may resolve within days of introduction. It has been reported to reduce seizure threshold in susceptible patients, but epilepsy is not considered an absolute contraindication. If ineffective, Baclofen needs to be weaned rather than abruptly withdrawn. Baclofen is a GABA (gamma aminobutyric acid) receptor agonist and as such has similar mode of action to Diazepam and Clonazepam which are occasionally used for spasticity management, but with less evidence for use.
- Tizanidine: This is usually used in addition to Baclofen if maximum dose of Baclofen is partially effective. Start at 2mg daily and increase in 2mg increments every 3-4 days aiming for 3-4 times daily dosing and a usual maximum of 24mg per day. QT prolongation and altered liver enzymes are possible, but uncommon, side effects to be aware of.
- There is no clear third choice agent and, typically if combinations of the above are unsuccessful, the next steps should be:
- Look for aggravating or trigger factors.
- Refer to specialist in spasticity management via physiotherapy or rehabilitation medicine departments. A focal treatment may be appropriate.
- Third choice medication options include:
- Dantrolene: This is associated with a 2% risk of hepatitis and should only be prescribed following specialist review and will require monitoring of liver function.
- Gabapentin: This may be used as a first line agent in situations where neuropathic pain is prominent.