Table 4.
| Medication | Dosea | Side Effects |
|---|---|---|
| Baclofen | Initial: 5 mg tid | Somnolence, dizziness, asthenia, constipation, nausea, poor muscle tone |
| GABA-B agonist (Level 1a) 1st line in SCI | Max daily dose: 80 mg divided into 3 to 4 doses | |
| Precaution: Dose adjustments in renal disease | ||
| Increase: 5 mg/dose every 3 days | Avoid abrupt discontinuation | |
| Tizanidineb Alpha-2 adrenergic agonist (Level 1a) | Initial dose: 2 mg daily | Somnolence, dry mouth, asthenia, dizziness, hypotension |
| Max daily dose: 36 mg in three divided doses | Precaution: Hepatotoxicity; monitor LFTs | |
| Increase: 2–4 mg over 2 to 4 weeks | ||
| Discontinuation: decrease dose by 2–4 mg per day | ||
| Gabapentin GABA analog (Level 1b) | Initial dose: 300 mg tid | Dizziness, somnolence, dry mouth, edema, constipation |
| Max daily dose: 3600 mg in three divided doses | Precaution: Dose adjustment in renal impairment | |
| Avoid abrupt discontinuation | ||
| Dantroleneb Peripheral calcium inhibitor (Level 1b) 1st line if SCI + cognitive dysfunction, otherwise 2nd line | Initial: 25 mg daily × 7 days | Muscle weakness (peripheral and respiratory) |
| Max dose: 100 mg qid | Sedation | |
| Increase: 25 mg tid × 7 days | Nausea, diarrhea | |
| 50 mg tid × 7 days | Precaution: Blackbox warning: Hepatotoxicity, symptomatic hepatitis; monitor LFTs | |
| 100 mg tid × 7 days | ||
| May cause more weakness in patients with marginal strength | ||
| Clonidine Alpha-2 adrenergic agonist (Level 1b) | Initial: 0.05 mg bid to 0.1 mg bid | Orthostasis, bradycardia, dry mouth, constipation, drowsiness |
| Max daily dose: 0.4 mg in two divided doses | Precaution: Abrupt discontinuation may lead to withdrawal symptoms (e.g., rebound hypertension, headache, agitation) | |
| Dose adjustment in renal impairment | ||
| Diazepam GABA-A agonist | Initial dose: 2 mg tid | Drowsiness, impaired memory, decreased attention |
| Max daily dose: 10 mg qid | Precaution: Tolerance, dependency; risk for withdrawal syndrome | |
| Caution in elderly | ||
| Avoid in alcohol |
Note: bid = twice daily; qid = four times a day; tid = three times a day.
aUpon discontinuation, gradual dose reduction for all medications is recommended. Risk of withdrawal is seen with abrupt discontinuation of baclofen, diazepam, clonidine, and gabapentin. For gabapentin, do gradual dose reduction, discontinuation, or substitution over a minimum of 1 week.
bMonitor liver function tests (LFTs) periodically with dantrolene and tizanidine at baseline, 1 month, 3 months, and 6 months.