Document Type

Conference Proceeding

Publication Date


Publication Title

J Gen Intern Med


CASE: A 64-year-old woman with a history of type 2 diabetes on long-term insulin complicated by gastroparesis, essential hypertension, and chronic kidney disease G5/A3 not on hemodialysis presented to the pain clinic 2 weeks prior to presentation for polyneuropathy and muscle spasms. She was prescribed gabapentin 100 mg three times daily and baclofen 5 mg 1-2 tablets three times daily. Two weeks after initiating baclofen, our patient fell at her home and was seen by family with bilateral shaking of upper extremities. Per family, the patient was confused but denied hitting her head or losing consciousness. She was brought to the Emergency Department for suspicion of stroke. The patient presented disoriented, lethargic and non-verbal with no focal deficits. Her presenting blood pressure was 215/98. She was admitted to the medical intensive care unit for hypertensive emergency with acute encephalopathy requiring continuous intravenous antihypertensive medication. Her physical exam demonstrated global encephalopathy but no focal neurological deficit. Her labs were significant for creatinine 3.96 (baseline 3.2) μmol/l. A brain computerized tomography (CT) without IV contrast showed stable chronic bilateral encephalomalacia in the cerebellar hemispheres with no acute intracranial abnormalities. Given her acute kidney injury superimposed on chronic kidney disease and persistent confusion despite resolution of hypertensive emergency, baclofen-induced encephalopathy was diagnosed. The patient underwent urgent hemodialysis with complete resolution of encephalopathy after the first 3.5h session. The patient underwent a second 4h hemodialysis session and was discharged 48 hours later with baseline mentation. IMPACT/DISCUSSION: Encephalopathy is a broad differential diagnosis including toxometabolic, infectious, traumatic, environmental and pharmacologic etiologies. Baclofen is a GABA agonist and acts through inhibition of pre-synaptic motor neurons to teat spasticity, pain, muscular rigidity, and spasms. As baclofen is primarily excreted by the kidneys, most cases of baclofen toxicity have been reported in dialysisdependent patients, usually 2-3 days to 6 weeks following ingestion of the drug. Intoxication signs and symptoms include seizures, autonomic disturbances, respiratory depression, and altered consciousness CONCLUSION: In patients with severe chronic kidney disease, baclofen should be avoided if possible. If baclofen cannot be avoided, it is important to initiate at low, renally-adjusted dosages. If toxicity is suspected, hemodialysis is an appropriate treatment to reduce clearance time and alleviate clinical symptoms.




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