Seizures Following High-Dose Baclofen With Alcohol
Seizures Following High-Dose Baclofen With Alcohol
The patient was a 46-year-old Caucasian male with a medical history of obesity (body mass index = 37 kg/m) and chronic obstructive pulmonary disease. He was seen for the treatment of alcohol abuse that had started 10 years previously and was determined to be consuming ~150 g/day of alcohol at that time. Despite numerous detoxification attempts, the patient was not able to maintain abstinence for >3 weeks over the 10-year period. He was treated several times with acamprosate and naltrexone, but neither of these medications helped him maintain abstinence or reduce the amount of alcohol consumed. The patient also smoked tobacco (40 cigarettes per day, 35 pack-years). He experienced a major depressive episode in 2005, which was treated with 20 mg/day mirtazapine. The patient's other medications included 20 mg/day lorazepam that had been prescribed for anxious symptoms and 7.5 mg/day zopiclone for insomnia. The general psychiatric state was stabilized when the patient was met. He had no history of neurological disorders and had never experienced seizures.
To care for the patient's treatment-resistant alcohol dependence, he was included in a system that provides a protocolized HDB prescription and reinforced supervision (Rolland et al., 2010). As planned by this protocol, the patient was informed that HDB would be delivered off-label, and despite the fact that it is a care protocol and not a research trial, we ask patients to provide a written consent before receiving this off-label medication. Moreover, the dose of baclofen was increased by 15 mg/day each week, i.e. 15 mg/day during the first week, 30 mg/day during the second week, and so on. Meanwhile, lorazepam and zopiclone were stopped. Ten weeks after the beginning of the treatment (see Fig. 1), the patient was receiving 120 mg/day of baclofen and reported a reduction in alcohol drinking from 150 to 50 g/day. This reduction was confirmed by his family and prompted an increase in the dose of baclofen. At Week 16, the patient reached the dose of 200 mg/day of baclofen, but his drinking level remained stable at ~50 g/day. The patient requested a further increase in the baclofen dose, and this increase was approved by a medical team, with the requirement that the patient's state be monitored every 2 weeks. Slightly >2 weeks later, while taking a dose of 240 mg/day, the patient experienced a period in which his drinking level dramatically increased; he later reported a period of 5 days during which he drank ~160 g/day. During this period, he experienced the first episode of tonic–clonic seizures, after which he was hospitalized. An electro-encephalogram and a computed tomography scan of the brain were performed, but neither found any anomaly. The patient left the emergency department the next day, and before we were able to see him, he consumed alcohol again and subsequently experienced a new episode of seizures. The patient was hospitalized a second time. When we met the patient, he did not agree to be hospitalized immediately. First, we checked whether the patient had any other risk factors for developing seizures (i.e. stress, infection or the introduction of another treatment). Second, we slowly began to reduce the baclofen dose to limit the risk of causing further seizures. The patient agreed to be hospitalized 10 days later. The baclofen dose was slowly reduced to 100 mg/day, and the patient received only 40 mg/day of diazepam and vitamins for 1 week. During this time, the patient did not experience any alcohol withdrawal symptoms. Since then, he has not experienced additional seizure episodes. The patient currently remains abstinent from alcohol but he is in an aftercare centre. The patient has not been put back on baclofen.
(Enlarge Image)
Figure 1.
Evolution of daily doses of alcohol and baclofen during the treatment of Mr O. During the 18th week, two consecutive episodes of seizures occurred at a 3-day interval, while both alcohol and baclofen were at their maximal levels.
Case Report
The patient was a 46-year-old Caucasian male with a medical history of obesity (body mass index = 37 kg/m) and chronic obstructive pulmonary disease. He was seen for the treatment of alcohol abuse that had started 10 years previously and was determined to be consuming ~150 g/day of alcohol at that time. Despite numerous detoxification attempts, the patient was not able to maintain abstinence for >3 weeks over the 10-year period. He was treated several times with acamprosate and naltrexone, but neither of these medications helped him maintain abstinence or reduce the amount of alcohol consumed. The patient also smoked tobacco (40 cigarettes per day, 35 pack-years). He experienced a major depressive episode in 2005, which was treated with 20 mg/day mirtazapine. The patient's other medications included 20 mg/day lorazepam that had been prescribed for anxious symptoms and 7.5 mg/day zopiclone for insomnia. The general psychiatric state was stabilized when the patient was met. He had no history of neurological disorders and had never experienced seizures.
To care for the patient's treatment-resistant alcohol dependence, he was included in a system that provides a protocolized HDB prescription and reinforced supervision (Rolland et al., 2010). As planned by this protocol, the patient was informed that HDB would be delivered off-label, and despite the fact that it is a care protocol and not a research trial, we ask patients to provide a written consent before receiving this off-label medication. Moreover, the dose of baclofen was increased by 15 mg/day each week, i.e. 15 mg/day during the first week, 30 mg/day during the second week, and so on. Meanwhile, lorazepam and zopiclone were stopped. Ten weeks after the beginning of the treatment (see Fig. 1), the patient was receiving 120 mg/day of baclofen and reported a reduction in alcohol drinking from 150 to 50 g/day. This reduction was confirmed by his family and prompted an increase in the dose of baclofen. At Week 16, the patient reached the dose of 200 mg/day of baclofen, but his drinking level remained stable at ~50 g/day. The patient requested a further increase in the baclofen dose, and this increase was approved by a medical team, with the requirement that the patient's state be monitored every 2 weeks. Slightly >2 weeks later, while taking a dose of 240 mg/day, the patient experienced a period in which his drinking level dramatically increased; he later reported a period of 5 days during which he drank ~160 g/day. During this period, he experienced the first episode of tonic–clonic seizures, after which he was hospitalized. An electro-encephalogram and a computed tomography scan of the brain were performed, but neither found any anomaly. The patient left the emergency department the next day, and before we were able to see him, he consumed alcohol again and subsequently experienced a new episode of seizures. The patient was hospitalized a second time. When we met the patient, he did not agree to be hospitalized immediately. First, we checked whether the patient had any other risk factors for developing seizures (i.e. stress, infection or the introduction of another treatment). Second, we slowly began to reduce the baclofen dose to limit the risk of causing further seizures. The patient agreed to be hospitalized 10 days later. The baclofen dose was slowly reduced to 100 mg/day, and the patient received only 40 mg/day of diazepam and vitamins for 1 week. During this time, the patient did not experience any alcohol withdrawal symptoms. Since then, he has not experienced additional seizure episodes. The patient currently remains abstinent from alcohol but he is in an aftercare centre. The patient has not been put back on baclofen.
(Enlarge Image)
Figure 1.
Evolution of daily doses of alcohol and baclofen during the treatment of Mr O. During the 18th week, two consecutive episodes of seizures occurred at a 3-day interval, while both alcohol and baclofen were at their maximal levels.
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