Muscle Relaxants and Antispasticity Agents

Benzodiazepines and Related Drugs in Orthopaedics

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Benzodiazepines are among the most commonly prescribed drugs worldwide and are often used as anxiolytics, hypnotics, anticonvulsants, and muscle relaxants.

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The risk of dependence on and abuse of these medications has recently gained more attention in light of the current opioid epidemic.

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Benzodiazepines can increase the risk of prolonged opioid use and abuse.

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Given the prevalence of the use of benzodiazepines and related drugs, orthopaedic patients are often prescribed these medications.

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Orthopaedic surgeons need to be aware of the prevalence of benzodiazepine and related drug prescriptions in the general population, their current uses in orthopaedic surgery, and the risks and adverse effects of their use.

Estimating the National Population of Hospitalized Chronic Baclofen Users: A Cross-Sectional Analysis of a Commercial Claims Database

Background

Baclofen is an effective treatment for spasticity. Abrupt cessation of intrathecal (IT) or oral baclofen risks the development of withdrawal symptoms; however, the magnitude of the problem is unknown.

Objectives

The aims for this study were as follows: (1) using an administrative claims database, estimate the number of patients in the United States on baclofen, and (2) estimate the annual percent hospitalized pediatric and adult populations consequently at risk for interruption of chronic baclofen therapy.

Methods

Using 2011–2014 data representing commercially insured individuals, patients were selected based on insurance coverage; evidence of a baclofen claim; and hospitalization. All patients hospitalized while receiving chronic baclofen were assumed to be at risk for baclofen discontinuation. Yearly counts were determined and then extrapolated to national estimates using census data.

Results

Extrapolating from the claims database, oral or IT baclofen was prescribed annually to 33,061 or 1486 patients ≤ 18 years, and 654,294 or 7084 patients 19–64 years, respectively. The estimated national mean number of at-risk hospitalizations per year for patients aged 19–64 years on chronic oral or IT baclofen was 31,116 and 3774, respectively; patients ≤ 18 years numbered 4691 and 959, respectively. The mean percent of patients hospitalized per year was 42% in those ≤ 18 years receiving IT baclofen compared with 30% in adults, and 3–10% in the populations receiving oral baclofen.

Conclusions

Extrapolation from an administrative claims database was used to estimate the national number and demographics of hospitalized chronic baclofen users. Patients ≤ 18 years receiving IT baclofen were at highest risk of withdrawal due to a high occurrence of hospitalization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-022-00293-8.

Are Patients Taking Benzodiazepines at Increased Risk for Complications Following Primary Total Knee Arthroplasty?

BACKGROUND

Benzodiazepines are commonly taken by patients who are undergoing total knee arthroplasty (TKA), but there is a paucity of studies evaluating any associations. Therefore, we hoped to study if patients taking preoperative benzodiazepines would have increased complications following TKA.

METHODS

Using a nationwide database, from 2010 to 2019, we evaluated patients undergoing primary TKA who either did or did not have a preoperative record of benzodiazepine prescription. We performed a multivariable logistic regression analysis, adjusting for multiple variables (age, gender, obesity, and Charlson comorbidity index), to determine the association of preoperative benzodiazepine use and adverse events in a matched cohort. Furthermore, we stratified patients by one vs multiple preoperative benzodiazepine prescription(s). We evaluated 90-day and 2-year rates of revision, resection, femur fracture fixation, manipulation under anesthesia (MUA), and delirium.

RESULTS

Patients filling more than one preoperative benzodiazepine prescription had increased adjusted odds of 90-day (odds ratio [OR] = 1.198, confidence interval [CI] = 1.086-1.320) and 2-year (OR = 1.188, CI = 1.125-1.254) revision; 90-day resection (OR = 1.430, CI = 1.125-1.817); 90-day (OR = 1.639, CI = 1.255-2.141) and 2-year (OR = 1.646, CI = 1.412-1.919) femur fracture fixation; and 2-year delirium (OR = 2.288, CI = 1.564-3.382). Preoperative benzodiazepine users had decreased adjusted odds of 90-day (OR = 0.670, CI = 0.639-0.702) and 2-year (OR = 0.702, CI = 0.671-0.734) MUA.

CONCLUSION

After controlling for multiple variables, benzodiazepine use was associated with increased rates of revision, resection, femur fracture fixation, and delirium. Furthermore, benzodiazepine use was also associated with a decreased rate of MUA. Orthopaedic professionals can counsel patients taking this group of medications about the associated adverse events. Future studies should assess the use of other muscle relaxants in the prevention of knee stiffness and MUA.

Single Residue Variation in Skeletal Muscle Myosin Enables Direct and Selective Drug Targeting for Spasticity and Muscle Stiffness

Muscle spasticity after nervous system injuries and painful low back spasm affect more than 10% of global population. Current medications are of limited efficacy and cause neurological and cardiovascular side effects because they target upstream regulators of muscle contraction. Direct myosin inhibition could provide optimal muscle relaxation; however, targeting skeletal myosin is particularly challenging because of its similarity to the cardiac isoform. We identified a key residue difference between these myosin isoforms, located in the communication center of the functional regions, which allowed us to design a selective inhibitor, MPH-220. Mutagenic analysis and the atomic structure of MPH-220-bound skeletal muscle myosin confirmed the mechanism of specificity. Targeting skeletal muscle myosin by MPH-220 enabled muscle relaxation, in human and model systems, without cardiovascular side effects and improved spastic gait disorders after brain injury in a disease model. MPH-220 provides a potential nervous-system-independent option to treat spasticity and muscle stiffness.

Morphine-induced Straub tail reaction in mice treated with serotonergic compounds

Constitutively active 5-HT₂ receptors have been suggested to contribute to motoneuronal excitability, muscle spasms and spasticity. Accordingly, 5-HT_2C receptor inverse agonists have been demonstrated in pilot experiments to reduce spasticity in animal model of spasticity and patients with spinal cord injuries. Thus, 5-HT_2C receptor inverse agonists may represent a novel class of anti-spasticity agents justifying a search for compounds with robust 5-HT_2C receptor inverse agonist activity either among the existing medications or via a dedicated drug discovery program. Morphine-induced Straub tail response in mice is regarded as a model of transient spasticity that may be suitable for supporting such drug discovery efforts. Subcutaneous injection of morphine (10-60mg/kg) induced a dose-dependent Straub tail reaction in male Swiss mice with maximum response obtained 15-30min after the morphine administration. When given prior to morphine, 5-HT_2B/2C receptor inverse agonists cyproheptadine (1-10mg/kg, i.p.) and SB206553 (0.3-3mg/kg, i.p.) diminished Straub tail reaction dose-dependently without affecting spontaneous locomotor activity. In contrast, 5-HT_2B/2C receptor antagonist methysergide (1-5.6mg/kg, i.p.) and 5-HT_2C receptor antagonist SB242084 (1-5.6mg/kg, i.p.) as well as 5-HT_2A receptor inverse agonist pimavanserin (1-10mg/kg, i.p.) had no appreciable effects on Straub tail response. Taken together, the findings indicate that constitutive activity of 5-HT_2B/2C receptor may be involved in the mechanisms of morphine-induced spasticity. Thus, morphine-induced Straub tail response may be evaluated further as a candidate higher throughput test to identify 5-HT_2C receptor inverse agonists with anti-spasticity effects in vivo.

Reduction of spinal sensory transmission by facilitation of 5-HT1B/D receptors in noninjured and spinal cord-injured humans

Activation of receptors by serotonin (5-HT1) and norepinephrine (α2) on primary afferent terminals and excitatory interneurons reduces transmission in spinal sensory pathways. Loss or reduction of descending sources of serotonin and norepinephrine after spinal cord injury (SCI) and the subsequent reduction of 5-HT1/α2 receptor activity contributes, in part, to the emergence of excessive motoneuron activation from sensory afferent pathways and the uncontrolled triggering of persistent inward currents that depolarize motoneurons during muscle spasms. We tested in a double-blind, placebo-controlled study whether facilitating 5-HT1B/D receptors with the agonist zolmitriptan reduces the sensory activation of motoneurons during an H-reflex in both noninjured control and spinal cord-injured participants. In both groups zolmitriptan, but not placebo, reduced the size of the maximum soleus H-reflex with a peak decrease to 59% (noninjured) and 62% (SCI) of predrug values. In SCI participants we also examined the effects of zolmitriptan on the cutaneomuscular reflex evoked in tibialis anterior from stimulation to the medial arch of the foot. Zolmitriptan, but not placebo, reduced the long-latency, polysynaptic component of the cutaneomuscular reflex (first 200 ms of reflex) by ∼50%. This ultimately reduced the triggering of the long-lasting component of the reflex (500 ms poststimulation to end of reflex) known to be mediated by persistent inward currents in the motoneuron. These results demonstrate that facilitation of 5-HT1B/D receptors reduces sensory transmission in both monosynaptic and polysynaptic reflex pathways to ultimately reduce long-lasting reflexes (spasms) after SCI.

Injury in an elderly population before and after initiating a skeletal muscle relaxant

BACKGROUND

Quality guidelines recommend avoidance of skeletal muscle relaxants in patients 65 years and older, but this recommendation is based on expert opinion, not evidence.

OBJECTIVE

To describe an elderly population using skeletal muscle relaxants and compare the incidence of physical injury among these patients before and after initiation of the medication.

METHODS

This was a retrospective, pre-post cohort analysis, with each patient serving as his/her own control. In a population of elderly patients who purchased a prescription for a skeletal muscle relaxant, the primary outcome was to compare the proportion of patients experiencing an injury in a 60-day period prior to initiating the drug to the proportion experiencing an injury in the 60 days immediately following the purchase date.

RESULTS

Of the 11,875 patients included in the study, 108 (0.9%) experienced an injury during the baseline period and 144 (1.2%) experienced an injury in the 60-day follow-up period (unadjusted OR 1.35; 95% CI 1.05 to 1.75; adjusted OR 1.35; 95% CI 1.01 to 1.81). A total of 333 patients needed to be treated with a skeletal muscle relaxant to result in 1 additional injury. Independent predictors of an injury included a history of an injury in the previous 6 months (OR 3.01; 95% CI 1.54 to 5.88) and older age (OR 1.06; 95% CI 1.04 to 1.09).

CONCLUSIONS

The absolute increase in risk of injury in this population using a skeletal muscle relaxant was small but statistically significant. Cautionary use of these medications in the elderly continues to be advisable, but their use in selected patients 65 years and older could be considered if the expected benefits outweigh the small increased risk of injury. More study is needed to quantify the benefits versus risks of these medications in this population.