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LETTERS TO EDITOR
Year : 2019  |  Volume : 67  |  Issue : 4  |  Page : 1120-1121

Baclofen-induced Coma and Respiratory Depression in a Patient with Cervical Spondylotic Myelopathy with Chronic Kidney Disease


Department of Neurosurgery, SRM Medical College Hospital and Research Centre, Kattankulathur, Kanchipuram, Tamil Nadu, India

Date of Web Publication10-Sep-2019

Correspondence Address:
Prof. Deiveegan Kunjithapatham
Department of Neurosurgery, SRM Medical College Hospital and Research Centre, Kattankulathur, Kanchipuram - 603 203, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.266260

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How to cite this article:
Jeyaselvasenthilkumar TP, Kunjithapatham D, Chinnasamy S, Ali MA. Baclofen-induced Coma and Respiratory Depression in a Patient with Cervical Spondylotic Myelopathy with Chronic Kidney Disease. Neurol India 2019;67:1120-1

How to cite this URL:
Jeyaselvasenthilkumar TP, Kunjithapatham D, Chinnasamy S, Ali MA. Baclofen-induced Coma and Respiratory Depression in a Patient with Cervical Spondylotic Myelopathy with Chronic Kidney Disease. Neurol India [serial online] 2019 [cited 2019 Sep 23];67:1120-1. Available from: http://www.neurologyindia.com/text.asp?2019/67/4/1120/266260




Sir,

Baclofen is primarily used in spinal cord disorders to limit spasticity. It induces inhibition at the presynaptic motor neuron leading to an anti-spastic response. Oral baclofen toxicity is extremely rare but can affect patients with impaired renal clearance even in very low doses.[1] The symptoms can vary from mild symptoms, such as ataxia or dystonia, to coma and respiratory depression [2] in patients with severely impaired renal function. Hemodialysis rapidly reverses these side effects.

A 64-year-old man from an endemic area of fluorosis presented with features of Cervical spondylotic Myelopathy He was started on oral baclofen 10 mg twice daily. There was no past history of any renal disease. His other medications were tablet acetaminophen and multivitamins. His investigations revealed that he was suffering from fluorosis with ossified posterior longitudinal ligament with extensive calcification of soft tissues of the neck [Figure 1] and [Figure 2]. Ultrasonogram abdomen suggested features of chronic medical renal disease. Three days after starting baclofen therapy, the patient was found unconscious with Glascow coma scale of 3/15. The patient was shifted to the intensive care unit where he developed severe respiratory depression. The patient was intubated and ventilated and underwent hemodialysis. After Hemodialysis1, the patient regained consciousness but was drowsy and not moving the limbs. After Hemodialysis3, the patient became conscious, obeying and regained preoperative neurological status. The patient was extubated after 4 days and discharged on day 7. The serum baclofen concentration measured was 0.62 μg/ml (0.08–0.40 μg/ml) just prior to hemodialysis. The serum baclofen concentration declined to 0.10 μg/ml after Hemodialysis 2.
Figure 1: 3D CT recon showing ossified Anterior longitudinal ligament

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Figure 2: CT scan showing calcification of anterior longitudinal ligament, posterior longitudinal ligament, and paraspinal soft tissue

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The exact mechanism of baclofen-induced neurotoxicity is poorly understood. Altered mental state is the commonest presentation. Baclofen toxicity usually presents 2–4 days after initiation of therapy but a period of up to 16 weeks has been described. Usually, patients recover well after Hemodialysis in a period ranging from hours to days.[3] Since baclofen is widely used for the control of spasticity as well as in other conditions, such as trigeminal neuralgia and hemifacial spasm; it is very much important for all of us to know that baclofen should be avoided in patients with impaired renal function. In an unfortunate situation where the patient develops features of toxicity, the treating physician should be aware that HD promptly reverses the toxicity.[4] Hemodialysis removes baclofen as effectively as normal kidneys.[5] The summary of various cases reported so far in the literature is summarized in [Table 1].
Table 1: Summary of cases reported so far in the literature

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Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Beladi Mousavi SS, Beladi Mousavi M, Motemednia F. Baclofen-induced encephalopathy in patient with end stage renal disease: Two case reports. Indian J Nephrol 2012;22:210-21.  Back to cited text no. 1
    
2.
Lauren M, Porter DO, Stephanie S, Merrick MD, Kenneth D. Katz MD. Baclofen toxicity in a patient with hemodialysis-dependent end-stage renal disease. J Emerg Med 2017;54:99-100.  Back to cited text no. 2
    
3.
El-Husseini A, Sabucedo A, Lamarche J, Courville C, Peguero A. Baclofen toxicity in patients with advanced nephropathy: Proposal for new labeling. Am J Nephrol 2011;34:491-5.  Back to cited text no. 3
    
4.
Wu VC, Lin SL, Lin SM, Fang CC. Treatment of baclofen overdose by haemodialysis: A pharmacokinetic study. Nephrol Dial Transplant 2005;20:441-3.  Back to cited text no. 4
    
5.
Brvar M, Vrtovec M, Kovac D, Kozelj G, Pezdir T, Bunc M. Haemodialysis clearance of baclofen. Eur J Clin Pharmacol 2007;63:1143-6.  Back to cited text no. 5
    


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