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Killam-Worrall L, Brand R, Castro JR, Patel DS, Huynh K, Lindley B, Torres BP. Baclofen and Tizanidine Adverse Effects Observed Among Community-Dwelling Adults Above the Age of 50 Years: A Systematic Review. Ann Pharmacother 2024; 58:523-532. [PMID: 37589096 DOI: 10.1177/10600280231193080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVE This review highlights adverse effects of baclofen and tizanidine in older community-dwelling adults. DATA SOURCES A literature search was conducted, including search terms of "adverse effect," "baclofen," "elderly," "falls," "fractures," and "tizanidine." Studies were included if they described community-dwelling adults aged 50 years and older who received oral baclofen or tizanidine. The Federal Drug Administration Adverse Event Reporting System (FAERS) data were compiled for adverse effect incidence. STUDY SELECTION AND DATA EXTRACTION The literature search was completed in July 2019 and updated in June 2023. Reviews performed by 2 independent reviewers yielded 15 records. FAERS identified 486 (baclofen) and 305 (tizanidine) adverse effects of interest. DATA SYNTHESIS Two retrospective cohort studies evaluating baclofen use in older adults showed increased hospitalizations for encephalopathy in chronic kidney disease (7.2% vs 0.1%) and end-stage renal disease (daily dose 20 mg or more; relative risk [RR] 19.8, 95% CI = [14.0-28.0]). Other articles were case reports; 10 articles reported dyskinesias, encephalopathy or disorientation, and drowsiness associated with baclofen, and 5 articles reported bradycardia and/or hypotension with tizanidine. The FAERS Public Dashboard revealed 12.1% and 28.7% overall incidence of adverse effects of interest, with a 27.8% and 29.2% incidence of falls for baclofen and tizanidine, respectively. Baclofen and tizanidine are associated with concerning adverse effects in older adults. Alternative agents should be considered, but, if necessary, providers should start at lower doses and increase slowly. CONCLUSIONS This review highlights the importance of using baclofen and tizanidine with caution in older adults.
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Affiliation(s)
- Lisa Killam-Worrall
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Romana Brand
- Wise Regional Health System Emergency Department, Decatur, TX, USA
| | | | | | | | - Bryn Lindley
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
| | - Brittany Palasik Torres
- Department of Pharmacotherapy, College of Pharmacy, University of North Texas Health Sciences Center, Fort Worth, TX, USA
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Kikuchi K, Tsukamoto K, Kikuchi H, Saito T, Mori F. Tizanidine-Induced Bradycardia Without Concomitant Medications: A Case Report. Cureus 2024; 16:e60581. [PMID: 38894773 PMCID: PMC11184462 DOI: 10.7759/cureus.60581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2024] [Indexed: 06/21/2024] Open
Abstract
A 37-year-old woman was admitted to our hospital due to a loss of consciousness. She had been taking 2 mg of tizanidine for two months to manage shoulder muscle pain at night. On admission, an electrocardiogram showed sinus bradycardia with a heart rate of 30 bpm and QT prolongation (QTc 495 msec). She had a temporary pacemaker inserted in the catheterization room, after which an improvement in her level of consciousness was observed. There were no apparent endocrine disorders or structural heart diseases. The administration was discontinued after admission, and 12 hours after admission, her heart rate normalized to a sinus rhythm of 70-100 bpm, and QTc improved to 431 msec. Therefore, she was diagnosed with tizanidine-induced bradycardia. Although reports of tizanidine-induced bradycardia are rare, tizanidine's central α2 agonistic effects can cause bradycardia, necessitating caution.
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Affiliation(s)
| | | | | | | | - Fumiaki Mori
- Cardiology, Yokohama Medical Center, Yokohama, JPN
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Mahajan R, Kalita J. Tizanidine Induced Hypotension: Report of a Case and Review of the Literature. Curr Drug Saf 2024; 19:313-316. [PMID: 37489780 DOI: 10.2174/1574886318666230725113855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/13/2023] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
INTRODUCTION Spasticity is a common sequelae of stroke, and often these patients receive anti-spastic drugs such as baclofen or tizanidine. Stroke patients have multiple co-morbidities such as hypertension, diabetes, and seizure. Tizanidine is an α2 and imidazole receptor agonist at a spinal and supraspinal level resulting in reduced central sympathetic outflow and causing hypotension rarely, especially in those receiving beta-blockers or angiotensin-converting enzyme inhibitors. CASE PRESENTATION We report a 56-year-old hypertensive male presenting with altered sensorium who had recurrent intracerebral hemorrhage with left spastic hemiplegia and focal seizures. He was on amlodipine, atenolol, telmisartan and oxcarbazepine. After 3 doses of tizanidine 2mg, his blood pressure dropped from 140/90 to 80/40 mmHg and pulse from 82 bpm to 44 bpm. His blood counts, serum chemistry, procalcitonin, and Trop I were normal. ECG revealed sinus bradycardia. After 8 hours of withdrawing tizanidine, his blood pressure became 110/70 mmHg, and on the next day, it became 140/82 mmHg. His attendants were taught physiotherapy to minimize spasticity. CONCLUSION This patient highlights the need for close monitoring of patients receiving tizanidine co-medication with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. These drugs have a synergistic effect on reducing the renin-angiotensin-aldosterone system, thereby hypotension and bradycardia.
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Affiliation(s)
- Roopali Mahajan
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
| | - Jayantee Kalita
- Department of Neurology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, Uttar Pradesh 226014, India
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Chaugai S, Dickson AL, Shuey MM, Feng Q, Barker KA, Wei WQ, Luther JM, Stein CM, Chung CP. Co-Prescription of Strong CYP1A2 Inhibitors and the Risk of Tizanidine-Associated Hypotension: A Retrospective Cohort Study. Clin Pharmacol Ther 2018; 105:703-709. [PMID: 30223305 DOI: 10.1002/cpt.1233] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 08/17/2018] [Indexed: 11/05/2022]
Abstract
Tizanidine, a widely used muscle relaxant that can lower blood pressure, is metabolized by the cytochrome P450 1A2 (CYP1A2). We studied 1,626 patients prescribed tizanidine and 5,012 prescribed cyclobenzaprine concurrently with a strong CYP1A2 inhibitor. The primary outcome was severe hypotension, defined as systolic blood pressure (SBP) ≤ 70 mmHg during periods of drug co-exposure. Severe hypotension occurred more often in the tizanidine group (2.03%; n = 33) than the cyclobenzaprine group (1.28%; n = 64); odds ratio (OR) = 1.60; P = 0.029. This difference remained statistically significant after adjustment for a log-transformed propensity score that included age, sex, race, Charlson's comorbidity index, and concurrent use of antihypertensive medications (OR = 1.57; P = 0.049). A sensitivity analysis that defined hypotension as SBP < 90 mmHg also yielded higher rates of hypotension among patients prescribed tizanidine. In conclusion, CYP1A2 inhibition increases the risk of hypotensive episodes associated with the use of tizanidine in routine clinical practice.
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Affiliation(s)
- Sandip Chaugai
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Megan M Shuey
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - QiPing Feng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Katherine A Barker
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - James M Luther
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.,Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Cecilia P Chung
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Li X, Jin Y. Irreversible profound symptomatic bradycardia requiring pacemaker after tizanidine/loxoprofen combination therapy: a case report. J Int Med Res 2018; 46:2466-2469. [PMID: 29587554 PMCID: PMC6023050 DOI: 10.1177/0300060518765009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A 37-year-old man suffered irreversible profound symptomatic bradycardia requiring a pacemaker 3 days after beginning tizanidine/loxoprofen combination therapy for neck pain. This combination therapy is prescribed frequently for joint pain; however, combining loxoprofen with tizanidine could increase the risk of symptomatic bradycardia that is both permanent and severe. Similar cases have not been reported. This case suggests that tizanidine should be used cautiously when combined with loxoprofen, and drug interaction screening should be performed.
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Affiliation(s)
- Xiaolin Li
- 1 Division of Nutrition, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang, People's Republic of China
| | - Yunpeng Jin
- 2 Division of Cardiology, The Fourth Affiliated Hospital of Zhejiang University School of Medicine, Yiwu, Zhejiang, People's Republic of China
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Profound symptomatic bradycardia requiring transvenous pacing after a single dose of tizanidine. J Emerg Med 2015; 48:458-60. [PMID: 25456780 DOI: 10.1016/j.jemermed.2014.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 10/07/2014] [Accepted: 10/12/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND We report a case of profound symptomatic bradycardia after a single dose of tizanidine. CASE REPORT A 93-year-old female became altered and was found to have hypotension and profound symptomatic bradycardia 30 min post ingestion of a single 4-mg dose of tizanidine at her physician's office. Emergency Medical Services was called to scene and patient was transported to our tertiary medical center. In the emergency department, the patient required intubation, vasopressor support, and transcutaneous pacing. An electrocardiogram revealed atrial fibrillation with slow ventricular response with a heart rate of 19 beats/min. The patient was transferred to the intensive care unit and subsequently taken for cardiac catheterization, where a transvenous pacer was placed. During the next few days, her vital signs and mental status improved, allowing for successful extubation. Before discharge, the patient received a single-chamber pacemaker. DISCUSSION Profound symptomatic bradycardia from a single dose of tizanidine has not been reported. A review of the patient's medications did not reveal a significant cytochrome P450 drug interaction to result in an adverse effect as previously reported in the literature. CONCLUSIONS Tizanidine should be used cautiously in elderly population and drug interactions screening should be performed.
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Palleria C, Leporini C, Chimirri S, Marrazzo G, Sacchetta S, Bruno L, Lista RM, Staltari O, Scuteri A, Scicchitano F, Russo E. Limitations and obstacles of the spontaneous adverse drugs reactions reporting: Two "challenging" case reports. J Pharmacol Pharmacother 2013; 4:S66-72. [PMID: 24347986 PMCID: PMC3853673 DOI: 10.4103/0976-500x.120955] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Introduction: Nowadays, based on several epidemiological data, iatrogenic disease is an emerging public health problem, especially in industrialized countries. Adverse drugs reactions (ADRs) are extremely common and, therefore, clinically, socially, and economically worthy of attention. Spontaneous reporting system for suspected ADRs represents the cornerstone of the pharmacovigilance, because it allows rapid detection of potential alarm signals related to drugs use. However, spontaneous reporting system shows several limitations, which are mainly related to under-reporting. In this paper, we describe two particular case reports, which emphasize some reasons of under-reporting and other common criticisms of spontaneous reporting systems. Materials and Methods: We performed a computer-aided search of Medline, PubMed, Embase, Cochrane library databases, national and international databases of suspected ADRs reports in order to identify previous published case reports and spontaneous reports about the ADRs reviewed in this paper, and to examine the role of suspected drugs in the pathogenesis of the described adverse reactions. Results: First, we reported a case of tizanidine-induced hemorrhagic cystitis. In the second case report, we presented an episode of asthma exacerbation after taking bimatoprost. Through the review of these two cases, we highlighted some common criticisms of spontaneous reporting systems: under-reporting and false causality attribution. Discussion and Conclusion: Healthcare workers sometimes do not report ADRs because it is challenging to establish with certainty the causal relationship between drug and adverse reaction; however, according to a key principle of pharmacovigilance, it is always better to report even a suspicion to generate an alarm in the interest of protecting public health.
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Affiliation(s)
- Caterina Palleria
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Christian Leporini
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Serafina Chimirri
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Giuseppina Marrazzo
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Sabrina Sacchetta
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Lucrezia Bruno
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Rosaria M Lista
- Azienda Sanitaria Provinciale di Cosenza, Farmacovigilanza Territorio Paola, Italy
| | - Orietta Staltari
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Antonio Scuteri
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Francesca Scicchitano
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
| | - Emilio Russo
- Department of Science of Health, School of Medicine, University of Catanzaro, Italy and Pharmacovigilance's Centre Calabria Region, University Hospital Mater Domini, Catanzaro, Italy
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