Baclofen Nursing Implications
Baclofen Nursing Pharmacology
From the drug class skeletal muscle relaxants, baclofen, a gamma-aminobutyric acid (GABA) agonist is an antispasmodic agent and muscle relaxant.
Although baclofen was originally developed to treat epilepsy in 1962, it was found to improve spasticity in a small number of patients. Baclofen was reintroduced in 1971 as a treatment for spasticity and was later approved by the FDA in 1977.
Baclofen is used to treat pain and spasticity or muscle stiffness and tightness caused by multiple sclerosis, spinal cord injuries, and other spinal cord diseases.
Baclofen works by acting on the nerves in the spinal cord, reducing the number and severity of muscular spasms caused by multiple sclerosis or other spinal disorders. It also helps with pain relief and muscle movement, it is available in tablet form or liquid solution, to be taken by mouth which is commonly prescribed three times a day, at regular intervals.
Indications of Baclofen
Baclofen is indicated for the following:
- Relief of voluntary muscle spasticity. Multiple sclerosis, various spinal lesions such as tumors of the spinal cord, syringomyelia, motor neuron disease, transverse myelitis, and traumatic partial section of the cord can all cause voluntary muscular spasticity.
- Reduction of voluntary muscle stiffness. Cerebrovascular accidents, cerebral palsy, meningitis, or traumatic brain injury in adults and children can all result to voluntary muscle stiffness.
In patients aged 0 to 18 years:
- Symptomatic treatment of cerebral spasticity. Particularly that caused by infantile cerebral palsy, as well as after cerebrovascular accidents or in the presence of neoplastic or degenerative brain disease.
- Symptomatic treatment of muscle spasms. Particularly that caused by infectious, degenerative, traumatic, neoplastic, or unknown causes in the spinal cord, such as multiple sclerosis, spastic spinal paralysis, amyotrophic lateral sclerosis, syringomyelia, transverse myelitis, traumatic paraplegia or paraparesis, and spinal cord compression.
Dosing Considerations for Baclofen
Treatment with baclofen should begin with a daily dose of 15 mg, given in divided doses if possible. The following dosage schedule is recommended, although it should be altered to meet the needs of each individual patient:
- 5 mg given three times a day for three days
- 10 mg given three times a day for three days
- 15 mg given three times a day for three days
- 20 mg given three times a day for three days
Symptom control is usually satisfactory with doses up to 60 mg per day, although careful adjustment is often required to fit the needs of each individual patient. If necessary, the amount can be gradually raised, although a daily maximum dose of more than 100 mg is not recommended unless the patient is in hospital and under close medical supervision.
In some circumstances, smaller, more frequent doses may be preferable over larger, more spaced ones. Some individuals may also benefit from using baclofen solely at night to relieve severe flexor spasms. A single dose taken about an hour before doing specified tasks such as showering, dressing, shaving, or physiotherapy can also help with mobility.
Patients over the age of 65 may be more prone to side effects, especially when baclofen is first introduced. Small doses should be used at first, and the dose should be titrated gradually in response to the reaction, all while being closely monitored. There is no evidence that the average maximum dose in older individuals differs from the average maximum dose in younger patients.
Treatment with baclofen should normally begin with a relatively modest dose (about 0.3 mg/kg per day), divided into 2-4 doses (preferably in 4 divided doses). The dosage should be gradually increased, at around one-week intervals, until it meets the child’s unique needs. For maintenance therapy, the average daily dosage varies between 0.75 and 2 mg/kg body weight. In children under the age of eight, the total daily dose should not exceed 40 mg. A maximum daily dose of 60 mg/day may be administered to children over the age of eight. Baclofen tablets are not recommended for children under the age of 33 kg.
Pharmacology of Baclofen
Pharmacodynamics of baclofen. Baclofen is an antispasmodic medication that relaxes muscles. It inhibits excitatory neurotransmitter release in presynaptic neurons while stimulating inhibitory neuronal signals in post-synaptic neurons. Baclofen is most widely utilized in oral forms. Baclofen has CNS depression qualities and can elicit sedation with tolerance, somnolence, ataxia, and respiratory and cardiovascular depression. Baclofen also mediates some antinociceptive effects and promotes stomach acid secretion, according to one cross-section of research.
Mechanism of action of baclofen. Baclofen’s exact mechanism of action is uncertain. Baclofen is a beta subunit agonist for gamma-aminobutyric acid (GABA) receptors expressed on pre- and post-synaptic neurons. Baclofen generates an influx of potassium into the neuron after binding to GABA receptors, resulting in hyperpolarization of the neuronal membrane and decreased calcium influx at presynaptic nerve terminals. As a result, presynaptic neurons achieve the action potential threshold at a slower rate, and postsynaptic motor neurons that innervate the muscle spindles have a lower action potential. Baclofen relaxes spasticity by inhibiting the transmission of both mono- and polysynaptic responses at the spinal cord. Baclofen may act on some voltage-gated calcium channels, although the therapeutic significance of this is unclear.
Pharmacokinetics of baclofen
- Absorption. Baclofen has a bioavailability of 70% to 85% when taken orally. It is readily absorbed through the gastrointestinal tract after oral treatment, with peak plasma concentrations reaching two to three hours after intake. About four hours after intrathecal delivery, the maximum effect is noted. Absorption is dosage-dependent and rises as the dose is increased. There is intrasubject variation in absorption. When compared to the fasted state, administration of oral baclofen suspension with a high-fat meal resulted in a 9 percent decrease in AUC and a 33 percent decrease in Cmax.
- Distribution. Baclofen has a distribution volume of 0.7 L/kg. Baclofen does not readily penetrate the blood-brain barrier because it is mostly water-soluble. Baclofen drug concentrations in the cerebrospinal fluid are around 8.5 times lower than in plasma.
- Biotransformation. Only a small amount of baclofen is metabolized. The major metabolite, β-(p-chlorophenyl)-4-hydroxybutyric acid, is produced through deamination and is pharmacologically inactive.
- Elimination. Baclofen has a plasma elimination half-life of 3 to 4 hours. Baclofen is essentially removed in its original form. Within 72 hours, the kidneys eliminate around 75% of the dosage, with metabolites accounting for the remaining 5%.
Baclofen withdrawal symptoms usually appear within hours to days after the oral or intrathecal drug formulations are stopped. It’s not a good idea to stop taking baclofen all of a sudden. Changed mental status, somnolence, seizure, hypothermia, respiratory depression, and coma are among symptoms of baclofen overdose.
Vomiting, lightheadedness, drowsiness, muscle hypotonia, accommodation difficulties, coma, respiratory depression, and seizures were all symptoms of a baclofen oral pill overdose. The majority of overdose symptoms are neurological, however, rare cardiovascular consequences such as hypertension, bradycardia, and tachycardia can occur.
Symptomatic therapy and gastrointestinal decontamination should be started in the event of an overdose. Gastric emptying should be conducted when the patient is awake by generating emesis and then undergoing lavage while preserving an adequate airway and breathing. Emesis would not be evident in people who are unconscious.
Side effects of Baclofen
The common side effects of baclofen may include the following:
- Increased need to urinate
- Frequent urination
- Trouble sleeping
- Unusual tiredness or weakness
- Loss of appetite
- Muscle or joint pain
- Numbness or tingling in the hands or feet
- Stomach pain or discomfort
- Stuffy nose
- Weight gain
Adverse Reactions to Baclofen
Adverse effects are most common during the beginning of treatment (for example, sedation, somnolence, and nausea) when the dosage is increased too quickly when large doses are used, or in elderly people. They are usually transient and can be reduced or eliminated by lowering the dosage; they are rarely severe enough to require medication withdrawal.
The following are the adverse reactions that may occur when taking baclofen:
- Signs of an allergic reaction to baclofen which include hives, difficult breathing, swelling of the face, lips, tongue, or throat.
- Severe drowsiness or lightheadedness
- Weak or shallow breathing
- Itching, tingling, or twitching in your hands, arms, feet, or legs;
- Dry mouth
- Visual impairment
- Drug overdose
The symptoms of baclofen overdose may include:
- Weak muscle tone
- Vision problems
- Difficulty breathing
Drug Interactions with Baclofen
The following are the interactions of baclofen with other drugs:
- Central nervous system (CNS) depressants. When baclofen is taken with other medicines that cause CNS depression and other muscle relaxants or alcohol, more sedation may result. Baclofen pre-treatment may also extend the duration of synthetic opioid-induced anesthesia and concomitant use of opioid and intrathecal baclofen has been linked to respiratory depression, as well as hypotension. Thus, careful monitoring of respiratory and cardiovascular functions is prioritized, especially in patients with cardiopulmonary disease and respiratory muscle weakness.
- Antidepressants. The effect of baclofen may be potentiated when used in conjunction with tricyclic antidepressants, resulting in significant muscular hypotonia.
- Antihypertensives. Using baclofen with anti-hypertensives at the same time is likely to cause hypotension. The anti-hypertensive medicine dosage should be adjusted accordingly.
- Agents that decrease renal function. Baclofen excretion may be reduced by drugs or medicinal products that have a significant impact on renal function, resulting in toxic effects.
- Decarboxylase inhibitors. There have been reports of mental disorientation, hallucinations, nausea, and agitation in Parkinson’s disease patients taking baclofen with a decarboxylase inhibitor. Parkinsonism symptoms have also been found to worsen. As a result, caution should be exercised when using baclofen and a decarboxylase inhibitor at the same time.
Cautions in Using Baclofen
- Nervous system and psychiatric disorders. Treatment with baclofen may aggravate porphyria, alcohol abuse, hypertension, psychotic disorders, schizophrenia, depressive or manic disorders, confusional states, or Parkinson’s disease. Patients with these disorders should be treated with caution and maintained under constant observation. Suicide and suicide-related occurrences have been documented among baclofen patients. In the vast majority of cases, the patients had additional risk factors for suicide, such as alcohol use disorder, depression, and/or a history of past suicide attempts. Drug therapy should be accompanied by close supervision of patients who have other risk factors for suicide. Patients (and the caregivers) should be made aware of the need to watch for clinical worsening, suicidal behavior or thoughts, or odd behavioral changes, and to seek medical help right once if these symptoms appear.
- Epilepsy. Baclofen can increase epileptic symptoms, however, it can be used as long as proper supervision and anticonvulsive therapy are maintained.
- Urinary problems. Neurogenic abnormalities influencing bladder emptying may improve as a result of baclofen treatment. Acute urinary retention may occur in people with pre-existing sphincter hypertonia; the medicine should be taken with caution in these patients.
- Renal Impairment. Patients with renal impairment who were given more than 5 mg of baclofen per day showed signs of overdosing. Baclofen should be used with caution in patients with renal insufficiency, and only if the predicted benefit justifies the potential danger in patients with end-stage renal failure (CKD stage 5, GFR 15 ml/min). In individuals with renal impairment using oral baclofen at dosages greater than 5mg per day, neurological signs and symptoms of overdose, including clinical features of toxic encephalopathy (e.g., confusion, disorientation, somnolence, and depressed level of consciousness), have been noted. Patients with decreased renal function should be continuously watched in order to detect early poisoning signs.
- Pregnancy. Baclofen should only be used if it is absolutely necessary during pregnancy, especially in the first three months. The treatment’s benefits for the mother must be carefully balanced against the child’s potential hazards. Baclofen is able to pass through the placental barrier.
- Laboratory tests. Serum levels of aspartate aminotransferase, alkaline phosphatase, and glucose have all been found to be high in rare cases. In patients with liver disease or diabetes mellitus, appropriate laboratory tests should be conducted to determine that no drug-induced alterations in these underlying disorders have occurred.
- Balance and posture. When spasticity is required to maintain upright posture and balance during locomotion, Baclofen should be administered with caution.
- Other cautions. Baclofen should be taken with caution in patients who are currently on antihypertensive medication. Baclofen should be taken with caution in patients who have had a stroke or who have respiratory or hepatic problems. Because undesirable effects are more likely to occur in the elderly and individuals with cerebral spasticity, a cautious dosing plan should be used.
Nursing Considerations for Patients on Baclofen
The following nursing considerations are observed when the patient is taking baclofen:
- The nurse should ensure that appropriate laboratory tests should be conducted in patients with liver disease or diabetes mellitus to determine that no drug-induced alterations in these underlying disorders have occurred.
- The nurse should inform the patient on how to use the medication safely and explain to the patient that although baclofen is effective as a muscle relaxant, its usage in the treatment of low back pain is restricted. It is not recommended to take the medication with opioids, sedatives, or hypnotics. Baclofen should not be used for an extended period of time.
- The nurse should educate the patient to take baclofen exactly as prescribed and not to take more or less of it or take the medication more often than prescribed by the healthcare provider.
- The nurse should assess the patient’s vital signs and ensure an adequate nutritional status.
- The nurse should advise the patient to get enough sleep and adequate rest periods.
- The nurse should assess and monitor the patient for signs and symptoms of baclofen overdose.
- The nurse should assess and determine if the patient has a rare inherited condition with galactose intolerance, total lactase deficiency, or glucose-galactose malabsorption because baclofen tablets have lactose and it is contraindicated for the patient.
- The nurse should instruct the patient not to drive or use machinery due to the side effects of baclofen which might affect the patient’s reaction time, this includes dizziness, drowsiness, somnolence, and vision impairment.
- The nurse should assess the patient for any allergies to other medications or any of the ingredients in baclofen tablets and oral solution.
- The nurse should advise the patient to take the medicine with food to prevent stomach upset.
- The nurse should determine and report to the healthcare provider if the patient is taking any of the following medications: anti-depressants, anti-anxiety, medications for mental illness, anti-seizure medications, sedatives, sleeping pills, or tranquilizers.
- The nurse should inform the patient to avoid taking alcohol and sleep-inducing pills because these can result in dangerous effects.
- The nurse should advise the patient that side effects may be felt such as drowsiness, dizziness, confusion, nausea, insomnia, headache, painful or frequent urination, and report side effects that persists or is severe.
- The nurse should instruct the patient not to take a double dose of the medicine to make up for a missed dose.
- The nurse should ensure that the patient is keeping all appointments with the healthcare provider.
- The nurse should ensure that the drug therapy should be accompanied by close supervision for patients who have other risk factors for suicide. Patients and their carers should be educated of the need to watch for clinical worsening, suicidal behavior or thoughts, or odd behavioral changes, and advised to seek medical help right once if the symptoms appear.
Nursing Diagnosis for Baclofen
Possible Nursing Diagnoses
- Disturbed Sleep Pattern related to the side effect of baclofen
- Acute Pain (headache) related to the side effect of baclofen
- Acute Confusion related to the side effect of baclofen
- Constipation/Diarrhea related to the side effect of baclofen
- Risk for Suicidal Ideation related to the side effect of baclofen
- Deficient Knowledge related to baclofen
|Baclofen Nursing Interventions||Rationale|
|Assess the patient for signs and symptoms of spasms and muscle cramping.||To confirm the indication for administering baclofen, which is a muscle relaxant.|
|Assess if the patient has stroke, seizure, suicidal thoughts, psychotic disorder, depression, or hallucinations.||Baclofen is generally contraindicated in patients with stroke, seizure, suicidal thoughts, psychotic disorder, depression, or hallucinations.|
|Check the patient’s allergy status.||Previous allergic reaction to baclofen may render the patient unable to take them. Alternatives to baclofen should therefore be considered in case of allergy.|
|Assess if the patient is pregnant or lactating.||Baclofen should be prescribed in caution to a pregnant woman as this drug is under pregnancy category C and must only be taken under the direction of the physician.|
|Perform a focused neurological assessment of the patient.||To confirm the indication for administering baclofen.|
|Assess the patient’s mucous membranes and his/her ability to swallow.||To check for any potential problems with administration, hydration, and absorption.|
To ensure that the right form of baclofen is given.
|For diabetic patients, frequently assess blood sugar levels.||Baclofen may cause an increase in blood glucose levels.|
Nursing Planning and Intervention
|Baclofen Nursing Interventions||Rationale|
|Administer baclofen with food at the same time everyday.||To ensure optimal absorption and therapeutic action by baclofen, as well as reduce possible gastrointestinal side effects.|
|If the patient is having difficulty in swallowing, cut the baclofen tablet in half, or crush the tablet and dissolve in water.||This will ensure adequate absorption of the drug being administered.|
|Educate the patient about the action, indication, common side effects, and adverse reactions to note when taking baclofen. Instruct the patient on how to self-administer baclofen.||To inform the patient on the basics of baclofen, as well as to empower him/her to safely self-administer the medication.|
|Monitor the patient’s input and output and commence stool chart.||Baclofen may cause diarrhea, constipation, or dysuria. Early detection of either side effect can help institute a bowel program and relieve them effectively.|
|Discourage alcohol intake when on baclofen.||Alcohol can increase the nervous system side effects of baclofen, such as irritability, dizziness, and drowsiness.|
|Conduct a review of the current medications of the patient and ensure that he/she takes baclofen with extreme caution while on the following drug classes:|
-Central nervous system (CNS) depressants
|These drug classes may interact with baclofen:|
|Help the patient with activities of daily living as needed.||Baclofen may cause fatigue, dizziness, and drowsiness which may put the patient at risk for injury. Therefore, patients on baclofen require close supervision when doing ADLs.|
|Inform the patient that baclofen may cause mood swings and this should be reported to any healthcare professional once noticed.||To inform the patient of the possible side effect of levetiracetam on his or her behavior and emotional state.|
|Baclofen Nursing Interventions||Rationale|
|Ask the patient to repeat the information about baclofen.||To evaluate the effectiveness of health teaching on baclofen.|
|Monitor the patient’s sleep pattern.||To ensure that the baclofen did not cause any significant disturbance in the patient’s sleep pattern.|
|If the patient has an existing kidney problem, monitor the kidney function closely while on baclofen.||Patients with declining renal function must be monitored closely when taking baclofen as this muscle relaxant is primarily excreted through the kidneys.|
|Monitor the patient’s emotional and behavioral status using a behavioral Chart or an intentional rounding chart.||Baclofen may cause changes in mood, suicidal thoughts, depression, irritability, and other psychological effects. These should be monitored closely to ensure the patient’s safety and to check if the dose needs to be reduced or the drug must be discontinued.|
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Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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