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Case notes I dependence

Low-dose baclofen for treatment of

Mohamed Al-Garhy MD, Sona Varghese MD Alcohol use disorder (AUD) is a and reduced heavy drinking with muscle relaxants may have dissuaded growing problem in the Arabian but with side-effects,­ providers from using baclofen for Gulf region. Although drug including weight loss, dizzi­ ­ness and AUD, but it is a reasonable alternative treatment for AUD has largely neurocognitive problems, often lead- when FDA-approved treatments fail. 4 remained the same in previous ing to discontinuation. Baclofen is primarily eliminated by Molecules such as the kidneys, so it can be used in liver years, the dosage of the and baclofen could broaden the impairment.10 Baseline renal tests has always been a treatment objectives, especially should be performed before admin- subject of interest. This report reduction of alcohol consumption, istering baclofen, and a negative highlights the case of a patient an objective that is more readily test obtained for women on low-dose baclofen and the accepted by some patients.5 of childbearing age. sustained improvement he Baclofen is a GABAb achieved with the treatment. agonist that is FDA approved for Presentation treating . Because GABA A 29-year-old male patient started lcohol dependence is managed transmission is down-regulated in using alcohol six years ago almost Athrough a combination of treat- chronic alcohol use disorder (AUD), daily. He developed tolerance grad- ment including pharmacotherapy it is a commonly targeted neuro- ually to reach a daily intake of more and psychosocial approaches. transmitter when developing medi- than 25 units. He developed uncom- Although psychosocial treatments cations for AUD.6 plicated alcohol withdrawal on are effective in reducing alcohol con- GABAa receptors are fast-acting attempting to reduce the amount or sumption and in maintaining absti- inhibitory ion channels, and its ago- to abstain. Prior to this he had no nence in many patients, 40% to 70% nists (eg ) have a history of substance misuse or psy- of patients resume drinking within a significant abuse and cross-­ chiatric disorders. He had never year after treatment.1 liability. GABAb receptors, however, been treated before in rehabilitation Over the last decade, a variety of are slow-acting through a complex centre and had no legal problems have been proposed as cascade of intracellular signals, and related to his alcohol use and no putative therapeutic agents for alco- therefore GABAb agonists such as family history of substance misuse or hol dependence based upon their baclofen have been studied for treat- psychiatric disorders. ability to modulate corticomesolim- ing addiction.7 Four years ago, he was brought by bic dopamine function.2 A double-blind, randomised, pla- his father to the emergency room of The Food and Drug Administra- cebo-controlled trial of baclofen Sheikh Khalifa Medical City (a gen- tion (FDA) in the USA has approved showed that a significantly higher eral hospital in Abu Dhabi, United three medications for the treatment number of patients who achieved Arab Emirates), having not gone to of alcohol dependence – , and maintained abstinence through- work for two months and being intox- and . out the experimental period were icated most of the day. He was admit- Although naltrexone is relatively found in the group of patients treated ted for the first time to a drug and well tolerated, the potential risk with fixed-dose baclofen compared alcohol inpatient treatment unit fol- of hepatotoxicity at high dose with subjects treated with placebo.8 lowing 24-hour observation in the requires caution when treating In studies for AUD, the side-effect­ medical ward for development of patients with liver disease. Moreover,­ profile for baclofen was relatively withdrawal symptoms from chronic as it is an opiate antagonist, it is con- benign. , fatigue, sleepiness, alcohol use. Prior to admission, he traindicated in alcoholics who also vertigo, and abdominal pain were was investigated for any medical use opiate.3 reported; overall, baclofen was found conditions. His liver enzymes and Short-term randomised trials have to be safe and to have no abuse liabil- gamma-glutamyl transpeptidase shown improved rates of abstinence ity.9 The addictive potential of other (GGT) were slightly elevated, but he

6 I Progress in Neurology and Psychiatry I Vol. 21 Iss. 3 2017 www.progressnp.com Alcohol dependence I Case notes

had no medical issues that would war- discharged after four weeks and since Declaration of interests rant immediate medical attention. then has remained sober and attends No conflicts of interest were declared. While on the ward, he denied regular follow-­­up visits in the outpa- symptoms suggestive of psychiatric tient clinic. His medication (baclofen Dr Al-Garhy is a Consultant disorders or other substance misuse. 20mg three times a day) is provided Psychiatrist and Dr Varghese is a He was diagnosed according to on a monthly basis. Liver enzymes Specialist Psychiatrist, both at the DSM-IV criteria as suffering from and GGT have returned to normal. Chemical Dependency Unit, Sheikh alcohol dependence. He was com- Psychosocial support is regularly pro- Khalifa Medical City, Abu Dhabi, menced on 20mg vided to prevent relapse with a focus United Arab Emirates. three times a day and thiamine on self-esteem and assertiveness 100mg daily. He completed the issues. His family supports him and References detoxification process safely and was he resumed work shortly after dis- 1. Swift RM. Drug therapy for alcohol dependence. N Engl J Med 1999;340:1482–90. discharged after one month. The charge from the inpatient unit. 2. Ma JZ, Ait-Daoud N, Johnson BA. Topiramate patient failed to attend the outpa- reduces the harm of excessive drinking: tient clinic following discharge. Discussion implications for public health and primary care. Addiction 2006;101:1561–8. A year later, he had two subse- A case of alcohol dependence with 3. Krishnan-Sarin S, O’Malley S, Krystal JH. quent readmissions, for four and multiple relapses has been Treatment implications: using neuroscience three weeks. He completed detoxifi- described: the patient’s condition to guide the development of new pharma­ cotherapies for alcoholism. Alcohol Res Health cation in both admissions, but again had been deteriorating until he was 2008;31(4):400–7. failed to adhere to follow-ups after commenced on baclofen. In our 4. Friedmann PD. Clinical practice. Alcohol use in adults. Engl J Med 2013;368:365–73. discharge. His relapses usually hap- experience, baclofen was shown to 5. Paille F, Martini H. Nalmefene: a new pened shortly after discharge mostly be effective even in small doses – as approach to the treatment of alcohol due to work stressors and poor moti- effective as other FDA-approved dependence. Subst Abuse Rehabil 2014;5: 87–94. vation to recover. In all the three medications – for alcohol use disor- 6. Garbutt JC, Kampov-Polevoy AB, Gallop R, et admissions after completion of ders. Baclofen in small doses could al. Efficacy and safety of baclofen for , he attended an inpa- help many patients to achieve com- dependence: a randomized, double-blind, placebo-controlled trial. Alcohol Clin Exp Res tient rehabilitation program for plete abstinence, which is the pri- 2010;34:1849–57. relapse prevention. mary goal in treating alcohol use 7. Robinson S, Meeks TW, Geniza Z. Medication His last admission was three years disorders. There is a growing need for alcohol use disorder: Which agents work best? Current Psychiatry 2014;13(1):22–9. ago, where he came voluntarily for for future research to reassess the 8. Addolorato G, Caputo F, Capristo E, et al. rehabilitation. Following detoxifica- current guidelines used in the treat- Baclofen efficacy in reducing alcohol craving and tion, he was started on baclofen 5mg ment of AUD. It is always important intake: a preliminary double-blind ran­domized controlled study. Alcohol Alcohol 2002:37;504–8. three times a day and over a two-week to discuss all options available with 9.Johnson BA. Update on neuropharma­ period, baclofen was increased grad- the patient and their families before cological treatments for alcoholism: scientific basis and clinical findings. Biochem Pharmacol ually to reach 20mg three times a day. initiating treatment. 2008;75(1):34–56. At that dose, the patient acknowl- 10. Addolorato G, Leggio L, et al. Dose-response edged that baclofen greatly reduced Acknowledgements effect of baclofen in reducing daily alcohol intake in alcohol dependence: secondary analysis of a his craving and he expressed total We are grateful to the patient and his randomized, double-blind, placebo-controlled indifference toward alcohol. He was family for their time and support. trial. Alcohol Alcohol 2011;46(3):312–7.

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