Stopping Medications in Complex Continuing Care: The Example of Baclofen and Dantrolene

ABSTRACT Background: Despite a lack of valid trials documenting their efficacy, baclofen and dantrolene are widely used to treat spasticity. Objective: The primary purpose of this project was to evaluate the effects of planned withdrawal of baclofen and dantrolene in consenting patients who were receiving complex continuing care. We also surveyed physicians and patients (or their substitute decision makers) for the reasons they considered when deciding to participate in the withdrawal program. Methods: In this descriptive study, data were collected before, during, and after the withdrawal intervention. A withdrawal protocol was used in which the clinical team performed individualized monitoring as a basis for making any withdrawal decisions. Results: Of 69 patients taking either baclofen or dantrolene, 29 were excluded from the withdrawal protocol primarily because of physicians’ decisions. Of the 40 eligible patients, 26 (65%) participated in the tapering protocol. Of these 26, 15 (58%) were able to discontinue the drugs, 6 (23%) had their doses reduced, 4 (15%) had no change in dose, and 1 patient died during tapering. Six (23%) had other changes made to their spasticity treatment, and 4 (15%) experienced improvements in other symptoms that could have been adverse effects of the antispasticity agents. Conclusions: More than half of the participating patients were able to have baclofen or dantrolene discontinued or the dose lowered; some had adjustments in other medications. Targeted medication withdrawal programs can be used to reduce unnecessary medication in patients receiving long-term care in an institutional setting. RESUME Historique : Malgre le manque d’essais valides confirmant l’efficacite du baclofene et du dantrolene, ces deux agents demeurent largement utilises pour traiter la spasticite. Objectif : Le principal objectif de cette etude etait d’evaluer les effets d’un sevrage planifie du baclofene et du dantrolene chez des patients consentants qui recevaient des soins continus complexes. Les medecins et les patients (ou leurs decideurs substituts) ont egalement ete sondes pour connaitre les raisons expliquant leur decision de participer au programme de sevrage. Methodes : Dans cette etude descriptive, les donnees ont ete collectees avant, pendant et apres le sevrage. Les decisions relatives au sevrage etaient fondees sur la surveillance individualisee des patients par l’equipe de soins cliniques, conformement a un protocole de sevrage. Resultats : Parmi les 69 patients qui recevaient du baclofene ou du dantrolene, 29 n’ont pas ete retenus pour suivre le programme de sevrage, principalement a cause de la decision du medecin. Des 40 patients admissibles, 26 (65 %) ont participe au protocole de diminution progressive des doses d’antispastiques. De ces 26 patients, 15 (58 %) ont pu completement arreter leur traitement, 6 (23 %) ont pu reduire leurs doses, 4 (15 %) ont conserve leurs doses initiales et un est decede durant le traitement degressif. Six patients (23 %) ont eu d’autres changements apportes a leur traitement antispastique et 4 (15 %) ont connu une reduction d’autres symptomes qui auraient pu etre des effets indesirables des antispastiques. Conclusions : Plus de la moitie des participants ont reussi leur sevrage de baclofene ou de dantrolene ou une reduction de leur dose de ces medicaments; certains ont eu des ajustements a leurs autres medicaments. Les programmes de sevrage medicamenteux cibles peuvent servir a reduire l’utilisation inutile de medicaments chez les patients en centres hospitaliers de soins de longue duree.