baclofen

INTRODUCTION

This article describes the outcomes of a tapering protocol for withdrawal of baclofen and dantrolene that is used in the Complex Continuing Care Program at the authors’ institution. The SCO Health Service in Ottawa, Ontario, has 348 complex continuing care beds, 98 rehabilitation beds, 36 palliative care beds, and 269 long-term care beds. Patients are admitted to the Complex Continuing Care Program with a wide variety of debilitating conditions. Some need institutional care for many years, and others are eventually rehabilitated to a lower level of care.

The authors’ institution is recognized for its well-trained, competent health care professionals (e.g., physicians, physiotherapists, occupational therapists, nurses, pharmacists) and involved caregivers (e.g., family, and friends) who collaborate closely on a daily basis.
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The problems associated with the high level of inappropriate prescribing for patients receiving long-term institutional care and the success of a cisapride tapering protocol at the authors’ institution have been previously reported. Specifically, a with­drawal protocol was successful in stopping cisapride therapy for 23 (66%) of 35 patients, without any adverse consequences. This led to a belief that a Targeted Medication Withdrawal Program would be a useful addition to regular medication review tools at the institution. It was postulated that the use of an institu­tion-wide withdrawal program with standard tapering recommendations and individualized monitoring protocols and with explicit support from the Pharmacy and Therapeutics Committee would support health care professionals in making decisions to withdraw medications that might not be helping patients.

A Drug Utilization Task Force was assigned responsibility for determining drugs that should have priority for medication withdrawal. After cisapride, the next group of drugs identified for possible withdrawal were the antispasticity agents baclofen and dantrolene.

Placebo-controlled and comparative trials attempting to document the efficacy of oral antispasticity agents have yielded inconclusive results. In many instances, this is because of the variability of spasticity and the lack of a sensitive, reliable, and functionally and symptomatically relevant assessment tool. Despite the inconclusiveness of the research, these agents remain in wide use, and many caregivers and patients have a clinical impression that the drugs work. As such, there appears to be a wide gap between the published evidence and the daily experience of those managing spasticity.
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