2. Introduction
A muscle relaxant is a drug which affects skeletal muscle function and
decreases the muscle tone
used to alleviate symptoms such as muscle spasms, pain, and hyperreflexia.
Muscle Relaxants classified as:
1.Neuromuscular Junction Blockers
1.1. depolarizing
1.2. Nondepolarizing muscle relaxant
2.Spasmolytics
3. 1.Neuromuscular Junction Blockers
Can be;
1.1. Depolarizing
1.2. Nondepolarizing Muscle Relaxants
Neuromuscular blockers act by interfering with transmission at the
neuromuscular end plate and have no central nervous system (CNS) activity.
Important for induction of muscle paralysis as part of preoperative general
anesthesia.
4. 2.Spasmolytics
Spasmolytics, also known as "centrally acting" muscle relaxants
Used to alleviate musculoskeletal pain and spasms and to reduce spasticity
Both neuromuscular blockers and spasmolytics are often called muscle
relaxants
It is often associated with cerebral palsy, multiple sclerosis, and stroke.
The generation of the neuronal Signals in motor neurons that cause muscle
contractions are dependent on the:
balance of synaptic excitation and
inhibition the motor neuron receives
5. What is muscle spasm?
Muscle spasms is defined as an involuntary muscular
contraction
A painful muscle spasm is typically referred to as a
muscle cramp
Spasticity is defined as a muscle tone disorder
characterized by hyperactive tonic stretch reflexes
thought to arise from an imbalance of excitatory and
inhibitory neurotransmitters
6. Spasmolytic agents generally work by either enhancing the level of
inhibition, or reducing the level of excitation
Inhibition is enhanced by mimicking or enhancing the actions of endogenous
inhibitory substances, such as GABA
The mechanisms underlying clinical spasticity appear to involve not only the
stretch reflex arc itself but also
Higher centers in the central nervous system (ie, upper motor neuron lesion),
with damage to descending pathways in the spinal cord resulting in
hyperexcitability of the alpha motoneurons in the cord.
8. Baclofen
Baclofen has commonly been used for its muscle relaxant effects in the treatment of
spasticity
Baclofen is as effective as diazepam in reducing spasticity
Causes much less sedation
Mechanism Of Action
Acts as a GABA agonist at GABAB receptors in the brain and spinal cord
Potassium Ion Conductance
Hyperpolarization
calcium ion influx
Release of excitatory neurotransmitters
substance P
9. Baclofen also inhibits neural function presynaptically
Reducing the in both the brain and spinal cord
It may also reduce pain in patients by inhibiting the release of substance P in
the spinal cord, as well
Studies have confirmed that intrathecal administration of baclofen can control
severe spasticity and muscle pain that is not responsive to medication by
other routes of administration
Partial tolerance to the effect of the drug may occur after several months of
therapy, but can be overcome by upward dosage adjustments to maintain the
beneficial effect
10. Pharmacokinetics
Metabolized in the liver and excreted in the urine
Baclofen can be administered orally as well as intrathecally
Baclofen is rapidly and effectively absorbed after oral administration
It is lipophilic and able to penetrate the blood-brain barrier
Approximately 35% of the drug is excreted unchanged in the urine and feces
side effects
Common are weakness, sedation, and dizziness
At higher doses, baclofen can cause seizures, ataxia, and hallucinations
Abrupt withdrawal should be avoided because it can precipitate
seizures and hallucinations
11. Diazepam
The benzodiazepines, such as diazepam, interact with
the GABAA receptor in the central nervous system
Its action in reducing spasticity is at least partly mediated
in the spinal cord because it is somewhat effective in
patients with cord transection
While it can be used in patients with muscle spasm of
almost any origin
Produces sedation in most individuals at the doses
required to reduce muscle tone
12. Tizanidine
Clonidine and other imidazoline compounds have also been shown to reduce
muscle spasms by their central nervous system activity.
Tizanidine is an agonist at α2 adrenergic receptor
Reduces spasticity at doses that result in significantly less hypotension
than clonidine
Neurophysiologic studies show that it depresses excitatory feedback from
muscles that would normally increase muscle tone, therefore minimizing spasticity
Several clinical trials indicate that tizanidine has a similar efficacy to other
spasmolytic agents, such as diazepam and baclofen, with a different spectrum of
adverse effects
13. Tizanidine is a centrally acting muscle relaxant that, through its alpha-2
adrenergic agonist properties
Thought to prevent the release of excitatory amino acids by suppressing
polysynaptic excitation of spinal cord interneurons
Even though tizanidine’s pharmacologic effect is similar to another alpha-2
agonist like clonidine, but
It possesses only a fraction of its blood pressure–lowering effect
14. OTHER CENTRALLY ACTING - SPASMOLYTIC DRUGS
Gabapentin
An antiepileptic drug that has
shown considerable promise as
a spasmolytic agent in several
studies involving patients with
multiple sclerosis
Pregabalin
is a new analog of gabapentin that
may also prove useful
Progabide and glycine
Have also been found in
preliminary studies to reduce
spasticity
Progabide is a GABAA and GABAB
agonist and has active metabolites,
including GABA itself
15. Glycine
Is another inhibitory amino acid neurotransmitter
It appears to possess pharmacologic activity when given orally and readily
passes the blood-brain barrier
Idrocilamide and riluzole
Newer drugs for the treatment of amyotrophic lateral sclerosis
Have spasm-reducing effects, possibly through
Inhibition of glutamatergic transmission in the CNS
16. Spasmolytic Drugs
Side Effects
Because of the enhancement of inhibition in the CNS
most spasmolytic agents have the side effects
Sedation
Drowsiness and
Dependence with long-term use
Several of these agents also have abuse potential, and their prescription is
strictly controlled!!!
17. The most commonly used muscle relaxant for non spasticity-related
muscle pain
Structurally, it resembles tricyclic anti-depressants(TCAs)
Its therapeutic effect is centrally mediated and carries no direct peripheral
action on the affected muscles
Its main pharmacologic action occurs at the brainstem and spinal cord
levels and is partially explained by a depressant effect on the descending
serotonergic neurons
Cyclobenzaprine
18. Methocarbamol
It is a centrally acting muscle relaxant that suppresses spinal polysynaptic
reflexes and has no direct effect on skeletal muscle
Orphenadrine
Structurally related to diphenhydramine and carries relativelystronger
anticholinergic and weaker sedative properties
Its exact mechanism of action is unknown
Common side effects include drowsiness and dizziness, followed by other
central nervous system effects such as agitation, hallucinations, and euphoria
19. Quinine
Antimalarial, antipyretic, analgesic, and muscle relaxant effects
Prescribed for the Rx of nocturnal leg muscle cramps
Increase the refractoriness of muscle and to decrease the excitability of the
neuromuscular endplate
Metaxalone
Metaxalone is a centrally acting muscle relaxant with an unknown mechanism
It is metabolized in the liver and excreted through the kidneys in the form of
metabolites
20. Carisoprodol
Carisoprodol is still a commonly prescribed muscle relaxant that should
caution owing to the
Potentially addictive properties of its main metabolite, meprobamate
Carisoprodol produces its muscle relaxant effect by depressing the
interneuronal activity at the
Spinal cord level aswell as in the descending tracts of the reticular
formation
It is not recommended in the pediatric age population
21. These neurotoxins exert their pharmacologic effect at the
neuromuscular junction (NMJ)
Prevent the calcium-dependent release of acetylcholine
Producing a state of temporary drug-induced denervation
The therapeutic effect can take up to 1 week to take place fully and can
last up to 3 months, at which point repeat injections can be considered
Caution should be exercised in using appropriate botulinum dosing to
avoid functionally limiting muscle weakness
22. Diazepam has commonly been used in the treatment of muscle spasm
especially in the acute setting
It belongs to a group of compounds called benzodiazepines
known for their potent anxiolytic, sedative, as well as muscle
Mechanism of action
Their main mechanism of action is through central potentiation
of the inhibitory g-aminobutyric acid (GABA) effect through presynaptic
Facilitation of GABA release
23. Antispastic drugs are principally used for the treatment of spasticity observed
in disease states with upper motor neuron pathology such as
Stroke
Spinal cord injury
Traumatic brain injury, and
Multiple sclerosis
All but two of these agents exert their clinical effect through centrally mediated
mechanisms
24. Dantrolene reduces muscle spasms by inhibiting the release of calcium
from the sarcoplasmic reticulum and does not directly affect the CNS
Because dantrolene tends to produce greater muscle weakness than
baclofen,
It should not be the first-line agent for patients who are capable of
ambulation