Download LETTER TO THE EDITOR Flaccid Paralysis Due to Chronic Baclofen

Alcohol and Alcoholism Vol. 48, No. 3, pp. 375, 2013
Advance Access Publication 15 March 2013
doi: 10.1093/alcalc/agt022
LETTER TO THE EDITOR
Flaccid Paralysis Due to Chronic Baclofen Overdosage
Alain P. Yelnik1, *, Patrick Sportouch1 and Franck Questel2
1
Physical Medicine and Rehabilitation Department, AP-HP, G.H. Saint Lariboisière-Fernand. Widal, University Paris Diderot, 200 rue du Faubourg Saint
Denis, Paris 75010, France and 2Internal Medicine and Addictology Unit, AP-HP, G.H. Saint Louis-Lariboisière-Fernand Widal, University Paris Diderot,
200 rue du Faubourg Saint Denis, Paris 75010, France
*Corresponding author: Tel.: +33-1-40-05-42-05; Fax: +33-1-40-05-48-51; E-mail: [email protected]
Oral baclofen taken at recommended doses (up to 80 mg per
day in many national formularies) usually has only a mild
clinical effect on spasticity reduction. On account of potential
adverse events, baclofen is usually considered as a secondline therapy in stroke patients. It may, nonetheless, be used
as a first-line therapy in multiple sclerosis (MS) and spinal
cord injury-related spasticity (Yelnik et al., 2009). On the
other hand, when intrathecally delivered, baclofen is an effective treatment for spasticity, especially in spinal injury
patients and in MS. A single injection at a dose as low as
50 µg leads to complete flaccidity.
We report the case of a 58-year old man with left lower
limb spastic paresis related to a parasagittal meningioma surgically treated 12 years ago. It had remained a distal paresis
without sensory impairment. No active movement of the foot
was possible, with spastic dystonia-induced varus and toe
clawing during walking. For walking, an ankle-foot orthesis
was required. The patient benefited from local treatment by
Botulinum injections about twice a year. In July 2012, in
order to reduce his alcohol consumption, a psychiatrist proposed baclofen treatment, slowly increasing from 10 to 200
mg per day. When we were consulted on 10th October, after
1 month of daily absorption of 200 mg, the patient was confused, complained of memory disorders and was virtually
paralyzed, unable to stand up alone or to walk. There was a
dramatic decrease of left lower limb motor control and also
right impairment. Moreover, deep tendon reflexes were
absent in the lower limbs and hard to find in the upper
limbs. Urinary incontinence was occasionally observed. The
patient was admitted to our department.
Brain imagery (magnetic resonance imaging (MRI)) was
normal except for the known remaining parasagittal hypodensity. Spinal and caudal imagery (MRI) revealed a
lumbar canal narrowed by arthrosis and discal projection.
Lower limb electromyography revealed axonal neuropathy,
probably alcohol-related. Evoked sensory cortical potentials
did not show any abnormalities of the central pathways.
Baclofen was reduced by 10 mg every 2 days. Six weeks
after admission, all reflexes were present, with the left exaggerated; motor control had been regained as spastic dystonia
of the lower limb; walking was possible anew; urinary
control was normal and neuropsychological tests revealed
no memory disorders except some elements of dysexecutive
syndrome.
Since imagery and electrophysiological exams failed to
explain the disorders and because complete recovery occurred as the baclofen was reduced, it would appear highly
probable that the high previous doses of baclofen had caused
the temporary transformation of spastic paresis into flaccid
paralysis.
It is unusual to observe flaccidity with oral baclofen,
except during acute intoxication with extremely high doses
(450–1250 mg) after suicidal or recreational use (Ghose
et al., 1980; Haubenstock et al., 1983; Perry et al., 1998).
The association in our patient of relatively high doses with a
mild alcohol-related neuropathy may have occasioned this
particularly pronounced effect with major functional consequences. Since use of high doses of baclofen is being practised by some in the treatment of alcohol addiction (Rigal
et al., 2012), it is important that unwanted effects are be
brought to the attention of all concerned parties.
REFERENCES
Ghose K, Holmes KM, Matthewson K. (1980) Complications of
baclofen overdosage. Postgraduate Med J 56:865–7.
Haubenstock A, Hruby K, Jäger U et al. (1983) Baclofen (Lioresal)
intoxication report of 4 cases and review of the literature.
J Toxicol Clin Toxicol 20:59–68.
Perry HE, Wright RO, Shannon MW et al. (1998) Baclofen overdose: drug experimentation in a group of adolescents. Pediatrics
101:1045–8.
Rigal L, Alexandre-Dubroeucq C, De Beaurepaire R et al. (2012)
Abstinence and “low-risk” consumption 1 year after the initiation of high doses of baclofen: a retrospective among “highrisk” drinkers. Alcohol Alcohol 47:439–4.
Yelnik AP, Simon O, Bensmail D et al. (2009) Drug treatments for
spasticity. Ann Phys Rehabil Med 52:746–56.
© The Author 2013. Medical Council on Alcohol and Oxford University Press. All rights reserved