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Spasticity often is managed most effectively by medications (see table). Baclofen acts on the nerves that control the spastic muscles at their site of origin in the spinal cord. It is the most common anti-spasticity medication used in MS, and most people respond well to it. The dose must be carefully determined for each individual; too little will be ineffective, whereas too much produces fatigue and a feeling of weakness because it interferes with the proper degree of stiffness needed for balance and erect posture. The correct dose usually is determined by starting at a low level and slowly increasing the dose until a maximal beneficial effect is obtained. The most common mistake when taking baclofen is to give up on it too soon, so that the dose never reaches the level necessary to attain proper relaxation. That dose may be as low as one half of a pill (5 mg) per day, but some people may need to take as much as 40 mg four times a day. Baclofen is only available as a generic and may be the least expensive medical treatment. Thus it is often the initial drug used.

Medications for the Management of Spasticity Medication Notes

Baclofen May produce weakness at higher

Tizanidine (Zanaflex®)

Sodium dantrolene (Dantrium®) Diazepam (Valium®)

dose

Often combined with baclofen; may produce drowsiness May produce weakness

Cyproheptadine HCl (Periactin®) Cyclobenzaprine HCl (Flexeril®)

Clonazepam (Klonopin®)

Highly sedating; most often used at night; may become addictive Sedating; most often used at night

Sedating; used primarily as an "add on" medication Used for back spasms; most often combined with other medications

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Medications for the Management of Spasticity

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Medication

Notes

Gabapentin (Neurontin®)

May ease spasms that are difficult to manage

Especially useful for nighttime spasms

Selegiline (Eldepryl®)

Especially useful for nighttime spasms

Carbamazepine (Tegretol®) Used for flexor spasms of the arm or leg

Tizanidine (Zanaflex®), a newer antispasticity medication, acts on a different area of the spinal cord than baclofen. It appears to be effective in decreasing stiffness and muscle spasm, with less effect on strength than many other drugs. It must be used carefully and slowly because sleepiness inevitably results if the dose is increased too rapidly. The starting dose is 2 to 4 mg up to a maximum of 36 mg per day. It is quite effective and may be combined with baclofen in problem situations. It is especially useful for nighttime stiffness and spasms. It is not uncommon for the night to be the worst time for stiffness and spasms. This appears to have something to do with the lack of outside stimulation to the nervous system, making it more sensitive to spasm.

Another medication that sometimes is used for spasticity is sodium dantrolene (Dantrium®), which acts directly on muscles. It is a very potent medication that needs to be used carefully. It may be helpful, but it also may induce weakness, even at low doses.

Cortisone

Effective for paroxysmal spasms; should only be used on short-term basis

Spasticity also may be reduced by diazepam (Valium®), which is most often used for the relief of spasms that occur at night. Its calming effect also helps to induce sleep, but its strong sedative effect limits its use during the daytime. Diazepam must be prescribed with caution because it may become addictive if it is used too frequently. Clonazepam (Klonopin®) is closely related to diazepam. Its main use has been to treat certain types of epilepsy. It produces significant relaxation, and thus may be used as an anti-spasticity medication. Like diazepam, it sedates and is best used at bedtime. When using diazepam or clonazepam, both the doctor and the person with MS must pay attention to the potential for chemical dependency. When properly used at appropriate doses, this is not a major problem. However, if the dose must be continually increased and the person is using the medication not for spas-ticity but as a crutch to escape the realities of the world, it should no longer be used.

Cyproheptadine (Periactin®) is an antihistamine that has anti-spasticity properties and may be a good add-on medication at certain times. Its sedating effect limits its use, but doses of 4 mg taken when needed may be helpful.

A drug that is commonly used for spasms in the muscles of the back is cyclobenzaprine HCl (Flexeril®). It acts quite specifically on these spasms, but also may relieve limb spasms. It usually works best in combination with one of the other antispasticity medications.

Gabapentin (Neurontin®) is a newer medication that has been approved for use in seizures. This medication also has antispastici-ty properties, and when it is taken in doses of over 1 gm per day often eases problematic spasms.

L-dopa (Sinemet®) is a Parkinson's disease medication that also decreases spasms, especially the painful spasms that tend to occur at night and may become especially prominent and painful. Many of the drugs available to treat Parkinson's symptoms can have similar effects on spasms and in difficult situations may be useful.

Any of these medications may become less effective when they are taken for a prolonged period (this is referred to as the develop ment of tolerance), and it may be necessary to stop taking them for a period of time, after which they may again become effective.

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