Drugs used in nocturnal leg cramps not listed here:

• Quinine sulphate, see 5.4 Antiprotozoal drugs

The underlying cause of spasticity should be treated and any aggravating factors (e.g. pressure sores, infection) treated.

Diazepam may improve spasticity at anxiolytic doses (see 4.1.2 Anxiolytics) but it also causes sedation and occasionally extensor hypotonus.

Please also refer to the NICE guideline NG220 for advice in the management of multiple sclerosis in adults (June 2022)

Baclofen

• Tablets 10mg (£1.45 = 84 tablets)
• Oral solution sugar free 5mg in 5ml (£2.75 = 300ml)
• Intrathecal injection 50 microgram/1ml, 10mg/5ml, 10mg/20ml, 36mg/12ml, and 60mg/20ml (unlicensed preparations)

Indications

• Chronic severe spasticity resulting from disorders such as multiple sclerosis or traumatic partial section of spinal cord

Dose

• Initially 5mg 3 times daily, gradually increased; usual maintenance dose up to 60mg daily in divided doses (maximum 100mg daily)

Dantrolene

• Capsules 25mg, 100mg (£43.07 = 100mg x 100 capsules)
• Injection 20mg

Indications

• Chronic severe spasticity of voluntary muscle
• Injection: malignant hyperthermia and neuroleptic malignant syndrome

Dose

• Initially 25mg daily, may be increased at weekly intervals to maximum 100mg 4 times daily; usual dose 75mg 3 times daily

Tizanidine

• Tablets 2mg, 4mg (£40.05 = 4mg x 120 tablets)

Indications

• Spasticity associated with multiple sclerosis or spinal cord injury or disease

Dose

• Initially 2mg daily as a single dose increased according to response at intervals of at least 3–4 days in steps of 2mg daily (and given in divided doses) usually up to 24mg daily in 3–4 divided doses; maximum 36mg daily

Notes

1. Tizanidine is an alpha2-adrenoceptor agonist indicated for spasticity associated with multiple sclerosis or spinal cord injury. It should only be initiated by a Specialist Neurologist for patients unable to tolerate dantrolene or baclofen.

Cannabis extract

Sativex

(Cannabidiol and dronabinol)

• Oromucosal spray containing 2.5mg/2.7mg per dose (£300.00 = 3 vials, 270 doses)

Indications

• Moderate to severe spasticity due to multiple sclerosis (defined as scoring 4 or more on a 0 to 10 patient-reported numeric rating scale) when other pharmacological treatments for spasticity are not effective

Dose

• Titrated according to response (refer to SmPC for details). Maximum dose = 12 sprays a day
• To continue treatment patients must achieve at least a 20% reduction in spasticity-related symptoms (on a 0-10 patient reported numeric rating scale) following a 4-week trial during which the company provides Sativex according to its pay-for-responders scheme (to be supplied from secondary care)

Notes

1. Treatment must be initiated and supervised by a physician with specialist expertise in treating spasticity due to multiple sclerosis
2. If the patient meets criteria to continue treatment after 4 week trial (see above) the GP may be asked to continue to prescribe Sativex. The specialist will continue to oversee the ongoing management of multiple sclerosis (including periodic review of the need for ongoing treatment).
3. If there are any changes in the severity of the patient's condition, concomitant medication or if troublesome adverse reactions develop, the GP should seek advice from the specialist.
4. SmPC recommends effective contraception throughout treatment and for 3 months after stopping in both men and women of childbearing potential. Patients on hormonal contraceptives should use an additional alternative, non-hormonal/reliable barrier method of birth control during Sativex therapy
5. The routine commissioning of Sativex is accepted in Devon for the treatment of spasticity due to multiple sclerosis only when specific criteria are met (see Commissioning Policy for more details)