The Journal of the Arkansas Medical Society Med Journal June 2020 | Page 15

Table 1. Differential Diagnoses
to consider when working up
suspected Baclofen Withdrawal
Sepsis
Myocardial Infarction
Pulmonary Embolism
Autonomic Dysreflexia
Delirium
Meningitis
Encephalitis
Non Convulsive Status Epilepticus
Hypocalcemia
Malignant Hyperthermia
DIC
Rhabdomyolysis
Due to the severe consequences, a high index
of suspicion should be maintained to avoid
overlooking a case of baclofen withdrawal, especially
in patients with an ITB pump. In these
patients, a logical etiology of baclofen withdrawal
is a pump malfunction, thus it is important
to have physical medicine and rehabilitation
interrogate the ITB pump in a timely manner
to ensure proper pump functioning. There are
many causes of ITB pump malfunction, ranging
from battery failure, catheter migration,
catheter kinking, and baclofen refill errors. 1
In our patient, the ITB pump was interrogated
and confirmed to be functioning properly,
making the diagnostic picture even more
clouded. It is important to note that a properly
functioning ITB pump does not rule out baclofen
withdrawal. If the ITB pump is functioning
as intended and baclofen withdrawal is still
suspected, careful review of dosage habits of
all medications should be further reviewed.
Medication withdrawal is often due to communication
errors that most frequently occur during
transitions in the setting of the patient’s health
care such as the peri-operative period or transitions
to and from skilled nursing facilities. 10
Additionally, many patients in need of ITB pump
suffer from neurologic conditions rendering them
unable to communicate their medication regimen.
In these circumstances, collateral history from
family or care givers and thorough chart review
is useful in determining the most up-to-date information
regarding the patient’s medication and
dosing habits. In our patient, detailed chart review
of outpatient ITB pump notes revealed that
the patient had been taking oral baclofen on a
scheduled basis rather than PRN as had been previously
charted, resulting in the patient being in
baclofen withdrawal despite receiving the intended
dose of baclofen from a functional ITB pump.
Adverse drug events such as withdrawal are the
second-most-common complication during hospitalization.5
In complicated cases, medication
withdrawal can be masked by other conditions,
making the true etiology of symptoms difficult to
ascertain. Previous charting can also contribute
to confusion due to the inherent ambiguity arising
from PRN medications. Thus, in every patient
encounter, it is important to review dosing habits
of all medication in order to make fully informed
decisions and minimize errors.
Conclusion
Baclofen withdrawal is a potentially lethal complication
that can be due to medication error or ITB
pump malfunction. These patients often suffer
from a nonspecific array of symptoms and often
have many comorbidities that cloud the diagnostic
picture, leading to delay in detection and
treatment of withdrawal. This case supports the
importance of reviewing dosing and compliance
for all medications with the patient to ensure
full and complete understanding of the patient’s
medications at every encounter. Resuming baclofen
dosing often leads to complete resolution
of symptoms. Thus, early recognition and
treatment is critical to minimize complications
and a prolonged hospital stay. In this case, early
medication reconciliation may have reduced or
eliminated the complications experienced during
hospitalization.
References
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Symptoms of recurrent intrathecal baclofen withdrawal
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9. Reeves RK, Stolp-Smith KA, Christopherson MW
(1998) Hyperthermia, rhabdomyolysis, and disseminated
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10. Tam VC, Knowles SR, Cornish PL, Fine N,
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Volume 116 • Number 12 JUNE 2020 • 279