Tizanidine
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Various toxicities: case report A 52-year-old woman experienced an increase in panic, anxiety and pain symptoms and somatic withdrawal symptoms including increased BP, tachycardia and hyperhidrosis following withdrawal, abuse, drug craving and overdose of tizanidine [route and times to reactions onsets not stated]. The woman was hospitalised because of therapy-resistant chronic pain syndrome and increased use of tizanidine at a dose of 4mg up to twelve times/day (48 mg/day) for high levels of pain and anxiety when weaning. She had a medical history of heartburn and reflux, morbid obesity, Roux-en-Y gastric bypass, endometriosis, surgery for hydrosalpinx, endometrial cysts and adnexectomy, abdominal pain, nausea, frothy vomit which created suspicions that the gastric pouch had slipped into a hiatal hernia, for which she underwent laparoscopic hiatoplasty surgery. In February 2019, she was hospitalised for the following month for psychiatric examination; at that time, she described intense feelings of anxiety when suffering from pain. Following pain attack, she took 1–2 pills of 4mg tizanidine that immediately alleviated her symptoms. At current presentation, diagnoses of abuse of nondependence substances, somatoform pain disorder and panic disorder were made. Tizanidine withdrawal was planned. She had been constantly increasing the doses of tizanidine for over 6 years because of which the withdrawal was planned with caution. She was unable to confirm who had prescribed her with tizanidine. At the time of admission, she was taking about 40mg tizanidine, in 6–8 portions a day. A slow tapering scheme was started with limiting the daily intake to maximum 32mg, divided into 4 portions of 8mg each. Following reduction, the woman experienced an increase of panic and pain symptoms along with somatic withdrawal symptoms including increased BP, tachycardia and hyperhidrosis. Additional treatment with lorazepam was initiated to reduce the anxiety symptoms and further dose tapering of tizanidine. However, reduction of tizanidine to 2–4 mg/day was not possible due to strong symptoms of pain and anxiety along with substance craving described by her. It required further 3 weeks to reduce the daily intake of tizanidine to 28mg, while receiving lorazepam. Over the following 2 weeks, further reduction was not tolerated due to strong withdrawal symptoms. Hence, treatment with clonidine was initiated. In the next 4 weeks, it was possible to stepwise reduce to dose of tizanidine 8mg per week. Also, lorazepam was tapered off. After 5 weeks, she was able to discontinue tizanidine. Also, clonidine was reduced following stable BP and was eventually discontinued. She received bisoprolol for BP management. Later, she was discharged without any signs of withdrawal or craving. Kitta A, et al. Using clonidine in the treatment of tizanidine abuse and withdrawal: a case report of a patient with somatoform pain disorder. Journal of Substance Use 25: 803515898 535-537, No. 5, 2020. Available from: URL: http://doi.org/10.1080/14659891.2020.1738
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