revised 2009-08-14 Pharmacology Table 3: Skeletal Muscle Relaxants page 1 of 1

Drug Usual Dose1,2,3,4,5 Monthly Cost6* Comments 1,2,3,4, 5

Antispasmodics-Nonbenzodiazepine
Carisoprodol 350mg QID $$ Metabolized to meprobamate, an addictive sedative-hypnotic agent. Concern over abuse and dependence. Controlled substance in
(Soma) some states. Recommend to avoid. Evidence does not support use beyond 2-3 weeks. Withdrawal symptoms may occur with
Carisoprodol/Aspirin discontinuation.
(Soma Compound)
Chlorzoxazone 250-750mg TID-QID $ Rare hepatotoxicity. May discolor urine orange or red.
(Parafon Forte DSC)
Cyclobenzaprine 5-10mg TID $$ 5mg dose associated with lower incidence of somnolence with efficacy similar to 10mg dose. TCA derivative-contraindicated in
(Flexeril, Fexmid) Max: 60mg/day patients with cardiac conduction abnormalities. Should not be used within 14 days of MAOIs. Anticholinergic side effects. Avoid in
elderly. Multiple drug-drug interactions (CYP3A4, 1A2, 2D6 substrate).
Cyclobenzaprine ER 15-30mg QD $$$$
(Amrix)
Metaxalone 800mg TID-QID $$$$ Associated with hypersensitivity reaction. Use with caution in mild-mod hepatic disease. Avoid use in severe renal or hepatic
(Skelaxin) dysfunction. Less CNS side effects, lack of abuse potential, and limited accumulation due to short half-life.
Methocarbamol 1500mg QID x 72 hours, $$ Use with caution in renal and hepatic disease and in patients with history of seizure disorder. May discolor urine brown-black or
(Robaxin) then 750mg QID green.
Orphenadrine 100mg BID $$$ Anticholinergic side effects-not recommended in elderly. Do not discontinue abruptly.
(Norflex)
Antispasticity
Baclofen 5mg TID $$$ Use with caution in renal dysfunction and in patients with history of seizure disorder. Do not discontinue abruptly.
(Lioresal) Max: 80mg/d
Dantrolene 25-100mg BID-QID $$$$ Limited CNS effects. Black-box warning about dose-related fatal or nonfatal hepatitis; avoid in hepatic disease. Discontinue if no
(Dantrium) Max: 400mg/d benefit after 45 days.
Antispasmodic and Antispasticity
Diazepam 2-10mg TID-QID $ Potential for abuse. Avoid in elderly and patients with renal or hepatic impairment. Multiple drug-drug interactions (CYP3A4, 2C19).
(Valium)
Tizanidine 2-4mg every 6-8 hours $$$$ May have gastroprotective effects. Frequent liver function monitoring recommended (may cause hepatotoxicity). May cause
(Zanaflex) Max: 36mg/day hypotension and bradycardia. Adjust dose in renal insufficiency. Avoid concomitant use with ciprofloxacin and fluvoxamine, use
caution with other CYP1A2 inhibitors.
*Cost based on generic when available for maximum daily dose. $: <$20; $$: $20-$50; $$$: $50-$100; $$$$: >$100

References
1. Max MB, Gilron IH. “Antidepressants, Muscle Relaxants, and N-Methyl-D-Aspartate Receptor Antagonists.” in Bonica’s Management of Pain, 3 rd ed. Loeser JD, Butler SH, Chapman CR, Turk
DC. Eds. Lippincott, Williams, Wilkins: Philadelphia; 2001: 1710-1726.
2. Toth PP, Urtis J. Commonly used muscle relaxant therapies for acute low back pain: a review of carisoprodol, cyclobenzaprine hydrochloride, and metaxalone. Clin Ther. 2004; 26: 1355-1367.
3. van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the Cochrane Collaboration. Spine
2003; 28: 1978-1992.
4. Lexi-Comp (Lexi-Drugs, Comp + Specialties) [computer program]. Lexi-comp; May 29, 2009.
5. See S, Ginzburg R. Skeletal muscle relaxants. Pharmacotherapy 2008;28:207-213.
6. www.drugstore.com accessed June 1, 2009.

VCU Chronic Nonmalignant Pain Curriculum

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