Baclofen toxicity in patients with severely impaired renal function

OBJECTIVE: To report the toxic effects of baclofen in patients with severely impaired renal function. DATA SOURCES: From 1991 to 1995, nine patients with severely impaired renal function (2 not receiving dialysis, 1 undergoing continuous ambulatory peritoneal dialysis [CAPD], and 6 receiving maintenance hemodialysis), who exhibited clinical toxicity after baclofen therapy at our hospital were included for analysis. Another seven cases from the literature obtained by computerized (MEDLINE) and manual (Index Medicus) search methods published between 1980 and 1995 were also reviewed. INTERVENTION: Among our nine patients, the six undergoing chronic hemodialysis and one not undergoing dialysis received early (< 48 h) hemodialysis after toxic symptoms developed. The patient undergoing CAPD received late hemodialysis (> 72 h), and the other patient who had not undergone dialysis received only supportive care. RESULTS: A review of these 16 cases revealed that most patients received only small doses and very short-term baclofen therapy. Altered consciousness was the major presenting feature. Severe acute complications, such as seizures and respiratory depression, were relatively uncommon among patients with severely impaired renal function. However, abdominal pain, which has previously rarely been reported, was noted in five of our nine patients. Most patients showed clinical improvement after hemodialysis. An analysis of these nine patients revealed that those who received early hemodialysis had a shorter recovery time than the patient who received only supportive care (2.71 +/- 0.42, respectively, vs. 9 d; p < 0.01). A lag of several hours between the end of the hemodialysis session and an improvement in the level of consciousness was noted. DISCUSSION: As most patients with severely impaired renal function developed toxic symptoms soon after initiating a low-dose baclofen regimen, the accumulated dosage was small and severe complications were less common. Abdominal pain may have occurred as a result of the gamma-aminobutyric acid-mediated cholinergic effect exerted by baclofen. The delay in conscious recovery after hemodialysis may be due to a delay in the clearance of baclofen from the central nervous system. CONCLUSIONS: Patients with severely impaired renal function generally develop baclofen intoxication soon after the initiation of low-dose therapy. Thus, the administration of baclofen, regardless of the dosage, in these patients is not appropriate. Abdominal pain, in addition to altered consciousness, is a common presenting feature in patients with renal failure who have baclofen intoxication. Hemodialysis is effective in alleviating the clinical symptoms and shortening the recovery time for such patients.

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