Life-threatening baclofen toxicity in ESRD: a case report

Baclofen, a GABA-B receptor agonist, is widely used to manage spasticity, alcohol use disorders, and chronic hiccups. However, baclofen toxicity is a significant concern, particularly in patients with renal impairment due to its primary renal excretion. This case report describes the diagnostic and management challenges of baclofen toxicity in an 82-year-old man with end-stage renal disease (ESRD) undergoing maintenance hemodialysis. The patient presented with symptoms of vomiting, decreased consciousness, and involuntary movements 5 days after initiating a low dose of baclofen (5 mg/day) for hiccups. Despite the low dosage, the patient exhibited severe neurological symptoms, including atypical athetosis-like involuntary movements, which are not commonly associated with baclofen toxicity. Given his impaired renal clearance, baclofen accumulation was suspected as the underlying cause. Hemodialysis was performed under mechanical ventilation due to concerns about respiratory suppression, leading to significant clinical improvement. The patient was successfully extubated and discharged after 14 days of hospitalization. This case underscores the critical need for heightened vigilance and cautious medication management when prescribing baclofen to patients with renal dysfunction, even at low doses, as they face a significantly elevated risk of toxicity. Early recognition and timely intervention, including hemodialysis, are essential in managing baclofen toxicity in this vulnerable population. Increased awareness of atypical neurological manifestations of baclofen toxicity is crucial for accurate diagnosis and effective treatment.