Version June 2024
| To obtain emergency consultation with a medical toxicologist, in the United States, call 1-800-222-1222 for the nearest regional poison control center. Contact information for poison control centers around the world is available at the WHO website and in the UpToDate topic on regional poison control centers (society guideline links). |
| Clinical features of overdose |
| Common vital sign abnormalities include hypothermia, hypoventilation, hypotension, and bradycardia. |
| Mild toxicity includes nausea, vomiting, and somnolence. |
| More severe manifestations include myoclonus, hypotonia, respiratory depression/failure, seizure, and/or coma. Severe baclofen toxicity can mimic anoxic brain injury or brain death with loss of brain stem reflexes. |
| Toxicity can develop from therapeutic dosing in chronic kidney disease given primarily renal elimination. |
| Both baclofen and phenibut, in either misuse or overdose, can produce paradoxical agitation; erratic behavior, delirium, paranoia, psychosis, and auditory and visual hallucinations have been reported. |
| Intrathecal baclofen overdose can rapidly cause severe toxicity similar to oral overdose; the hypotonia often progresses in a rostral direction. |
| Diagnostic evaluation |
| All symptomatic patients |
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| Treatment |
| Supportive care |
| CNS depression: Most patients with CNS depression from baclofen or phenibut poisoning recover uneventfully, but many will require tracheal intubation for airway protection or hypoventilation. |
| Decreased respiratory rate with CNS depression: Naloxone 0.4 to 2 mg IV/IM/IN (children <5 years or ≤20 kg: 0.1 mg/kg/dose IV/IM/IN; maximum 2 mg dose). Naloxone would not be expected to reverse the effects of baclofen or phenibut itself, but may improve mental status or respiration if the patient has concomitant opioid intoxication. |
| Tachycardia and/or hypotension: IV isotonic saline or lactated Ringer (10 to 20 mL/kg, maximum 1 L) boluses |
| Seizures or agitation (for dosing, timing, and alternative medications for refractory seizures, refer to UpToDate content on convulsive status epilepticus): Benzodiazepines are first-line treatment (eg, lorazepam 2 to 4 mg IV/IM in adults; children: 0.1 mg/kg IV, maximum dose 4 mg). |
| Routine gastrointestinal decontamination with activated charcoal for isolated baclofen or phenibut ingestion is typically not needed since intoxication will improve with supportive care. |
| Extracorporeal removal |
| Hemodialysis effectively clears baclofen. It should be performed in a patient with severe poisoning (eg, coma or respiratory failure with need for mechanical ventilation) and severe kidney impairment (refer to UpToDate content for specific criteria). |
| Withdrawal syndromes |
| Daily use of baclofen or phenibut or intrathecal baclofen pump malfunction can lead to the development of tolerance, dependence, and life-threatening withdrawal symptoms with abrupt cessation of therapy. |
| Maintain a high degree of suspicion for baclofen withdrawal in patients with chronic baclofen use who present with hyperthermia, altered mental status, and increased muscle tone (spasticity or rigidity). Other symptoms may include anxiety, insomnia, pruritis, tachycardia, hypertension, myoclonus, and seizures. |
| The treatment goal of baclofen withdrawal is emergent baclofen administration via the same route as prior to cessation. If the patient has an intrathecal pump, the clinician who manages the pump should be contacted. |
| Phenibut withdrawal can be treated with benzodiazepines, baclofen, barbiturates, or propofol (if secure airway). |
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