tizanidine

[bedrock]

Seems like PCPs are always freaking out about tizanidine. I used it regular in PMR residency without concern and later as a pain physician.

I can understand hypotension risk in the elderly but what other common issues are there?

I saw a 26 yr old today with an early spondy, failed interventions/PT, has leg spasms at tizanidine 4mg QID PRN really helps here, but her PCP is worried about liver damage.....despite never checking LFTs and her having no GI symptoms of any kind.

What real risks do you consider when writing for tizanidine?

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[lobelsteve]

Sedation. Great sleeper. Hypotension 1 in 50 due to clonidine like effect. Have seen hallucinations rarely. Counsel regarding quinolone abx.

 

[DrMDAware]

So what do you prescribe for the elderly where Beer’s Criteria does not encourage baclofen, robaxin, flexeril?

Yeah yeah yeah I know muscle relaxants aren’t true relaxants, shouldn’t be used for long term use, some are actually a TCA, no evidence showing efficacy, patients should fix their posture etc but for those of us outside academia where the real world is what’s a reasonable medication to take the edge off juuuuust a bit?

 

[bedrock]

Thank you.

Sedation. Great sleeper. Hypotension 1 in 50 due to clonidine like effect. Have seen hallucinations rarely. Counsel regarding quinolone abx.

Was not aware of quinolone interact but otherwise what I thought. Not sure why all the PCPs are going nuts about it.

 

[Baron Samedi]

So what do you prescribe for the elderly where Beer’s Criteria does not encourage baclofen, robaxin, flexeril?

Yeah yeah yeah I know muscle relaxants aren’t true relaxants, shouldn’t be used for long term use, some are actually a TCA, no evidence showing efficacy, patients should fix their posture etc but for those of us outside academia where the real world is what’s a reasonable medication to take the edge off juuuuust a bit?

Those people don't need to be seen by a pain subspecialist. Let the PCP figure that part out.

 

[VA Hopeful Dr]

Those people don't need to be seen by a pain subspecialist. Let the PCP figure that part out.

Sure they do. After I've tried NSAIDs, muscle relaxers, PT, and something like Cymbalta or Pamelor and they still have significant pain, what else do you want me to do other than refer to you?

 

[Baron Samedi]

Sure they do. After I've tried NSAIDs, muscle relaxers, PT, and something like Cymbalta or Pamelor and they still have significant pain, what else do you want me to do other than refer to you?

But we were talking about patients who are overall fine but want something now and then to take the edge off.

 

[DrMDAware]

But we were talking about patients who are overall fine but want something now and then to take the edge off.

I like this. Any recommendations on how to convey this to patients?

On one hand I’m slightly annoyed to be writing it especially without a visit. However, on the other hand it is an easy visit and presents an opportunity to talk about a possible procedure that could help them more.

Sounds like a terrific patient for a PA

 

[Baron Samedi]

I like this. Any recommendations on how to convey this to patients?

On one hand I’m slightly annoyed to be writing it especially without a visit. However, on the other hand it is an easy visit and presents an opportunity to talk about a possible procedure that could help them more.

Sounds like a terrific patient for a PA

"Mr/s. ____, I'm glad we had a chance to go over your imaging and talk about some of the treatment options. I tend to treat people who have debilitating pain that interfere with their ability to do the things in life that they enjoy every day. My typical treatments involve invasive procedures that have some risks associated with them or daily medications that have the potential for side effects. I'm glad that you aren't at the point where you need those sorts of treatments. I'd recommend you talk to your Primary Care Provider about less invasive treatment options, and if you ever get to the point where you feel like your pain is becoming more constant or debilitating, please come back and see me anytime."

 

[clubdeac]

So what do you prescribe for the elderly where Beer’s Criteria does not encourage baclofen, robaxin, flexeril?

Yeah yeah yeah I know muscle relaxants aren’t true relaxants, shouldn’t be used for long term use, some are actually a TCA, no evidence showing efficacy, patients should fix their posture etc but for those of us outside academia where the real world is what’s a reasonable medication to take the edge off juuuuust a bit?

So for my frail and elderly, skelaxin supposedly is the least sedating muscle relaxant. I have had good success with flector patches in place of oral NSAIDs. They seem to work better than voltaren gel which typically doesn't do squat. Tylenol up to 2000mg qd. Maybe a lidoderm patch and tramadol or Tylenol #3 if they really need something stronger

 

[bedrock]

So for my frail and elderly, skelaxin supposedly is the least sedating muscle relaxant. I have had good success with flector patches in place of oral NSAIDs. They seem to work better than voltaren gel which typically doesn't do squat. Tylenol up to 2000mg qd. Maybe a lidoderm patch and tramadol or Tylenol #3 if they really need something stronger

I agree that flector patches seem to work better than voltaren. Lidoderm also seem to work better than lidocaine gel.

Must be something about the patch that encourages deeper absorption

 

[lobelsteve]

The power of belief.

 

[DrMDAware]

"Mr/s. ____, I'm glad we had a chance to go over your imaging and talk about some of the treatment options. I tend to treat people who have debilitating pain that interfere with their ability to do the things in life that they enjoy every day. My typical treatments involve invasive procedures that have some risks associated with them or daily medications that have the potential for side effects. I'm glad that you aren't at the point where you need those sorts of treatments. I'd recommend you talk to your Primary Care Provider about less invasive treatment options, and if you ever get to the point where you feel like your pain is becoming more constant or debilitating, please come back and see me anytime."

What if you’ve done the intervention and they ask for said medication to keep things going?

 

[lobelsteve]

What if you’ve done the intervention and they ask for said medication to keep things going?

Don't go down the rabbit hole of chasing procedures with meds. Pills for shots is a lucrative and popular practice model.
Think of muscle relaxant class (except Soma) as opiate/NSAID sparing agents. Something not OTC, not a scheduled drug, that can help a patient complete home exercises, take before/after getting out for cardio or after work/yardwork.
No one needs meds to sit around the house and watch TV. Carrot/stick. The goal is improved health/QOL while minimizing risk.

 

[Doctodd]

rum

 

[Ducttape]

failing everything that we prescribe doesnt mean they have tried all treatments.

they could try non-sanctioned treatments such as CBD, medical marijuana at their own peril.

those will probably fail.


drusso probably should stop reading now, but it might be time for these particular patients to rethink their pain is and what it means to them, especially if they are 26.

 

[DrMDAware]

Don't go down the rabbit hole of chasing procedures with meds. Pills for shots is a lucrative and popular practice model.
Think of muscle relaxant class (except Soma) as opiate/NSAID sparing agents. Something not OTC, not a scheduled drug, that can help a patient complete home exercises, take before/after getting out for cardio or after work/yardwork.
No one needs meds to sit around the house and watch TV. Carrot/stick. The goal is improved health/QOL while minimizing risk.

I respectfully disagree that I run an injection for pills practice. As you know these aren’t opioids. The muscle relaxer is a “appetizr” until the main course comes. They also help take off the edge during PT and excessive activity.

I conceptually understand the push for interventions. However with a large practice sometimes some patients aren’t candidates for any interventions and turning them away with nothing wouldn’t satisfy them much or the referring sources. If that is a muscle relaxant so be it. It’s not an opioid.

If they take the muscle relaxant and that is “enough” and they avoid an injection all the better.

 

[Laryngospasm]

We have enough to worry about without getting all worked up over muscle relaxants.