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10.2 Drugs used in neuromuscular disorders

10.2.1 Drugs which enhance neuromuscular transmission

Neostigmine tablets, injection
Edrophonium injection
Pyridostigmine tablets


10.2.2 Skeletal muscle relaxants

Baclofen tablets, liquid, intrathecal injection - see note re: withdrawal reactions
Dantrolene capsules, injection - see note
Diazepam tablets, syrup, emulsion injection
Quinine bisulphate tablets (see note)
Tizanidine tablets (see note below)

1. Intravenous dantrolene – There is a risk of skin and injection site reactions from undissolved crystals. Use a filter needle to draw up the reconstituted solution to minimise risk – see MHRA drug safety update July 2014

2. Serious psychiatric reactions can occur if baclofen is stopped abruptly: symptoms include hallucinations, paranoia, delusions, psychosis, confusion, and agitation. Convulsions have also been reported. In order to minimise the risk, baclofen therapy should always be discontinued by gradual dose reduction over at least one to two weeks. If symptoms occur, a longer period of withdrawal may be necessary.   

3. Quinine is not a routine treatment for nocturnal leg cramps. Benefits are considered to be modest (perhaps one episode per week less than with placebo). It should only be considered when cramps cause regular disruption of sleep, when the cramps are very painful, or frequent and when other treatable causes have not worked (e.g. passive stretching exercises). After an initial trial of 4 weeks, treatment should be stopped if there is no benefit. Treatment should be interrupted approximately every 3 months to reassess benefit; in those using quinine long term, a trial of discontinuation may be considered. Quinine has dose-dependent QT-interval-prolonging effects and should be used with caution in patients with risk factors for QT prolongation or in those with atrioventricular block (link to DSU)

Quinine has significant toxicity in overdose, especially in children, which can result in death or permanent visual loss.

4. Tizanidine - third-line use after considering benzodiazepine/gabapentin and baclofen. Handover to GP would be expected after a 4 month period of dose stabilisation / LFT monitoring.

5. Patients who are receiving benzodiazepines for extended periods of time should be reviewed by their prescribers on a regular basis so that their suitability for long term prescribing can be assessed. When withdrawing benzodiazepines the patient should be monitored closely during this period. Advice on withdrawing patients from benzodiazepines is available on the CKS website

For link to BNF section: 10.2 Drugs used in neuromuscular disorders