Tizanidine Withdrawal and Tapering

Can tizanidine cause withdrawal?

While uncommon, tizanidine can cause withdrawal symptoms when it is stopped, particularly after prolonged and high-dose use, or if it is stopped suddenly. 

Tizanidine is a centrally acting alpha-2-adrenergic agonist, which works as a muscle relaxant. It is used in the treatment of spasticity associated with conditions such as multiple sclerosis (MS) and spinal cord or brain injury. ^[1]

Tizanidine can be used as a short-term off-label treatment, such as in the management of insomnia and migraines. It can also be used longer term, such as in the treatment of MS spasticity or other chronic conditions. As such, there may be many circumstances in which tizanidine use is stopped, such as if it is no longer required or if serious adverse effects have occurred. ^[1]

Most drugs that act on the central nervous system (CNS) cause biological changes during prolonged use, which can lead to withdrawal symptoms when use is stopped. Because of this, it is recommended that these types of medications, such as tizanidine, be reduced gradually when they require discontinuation, to help prevent or reduce withdrawal symptoms. ^[2]

Tizanidine causes changes such as reduced adrenaline levels. This means that when it is stopped, there can be a sudden surge of adrenaline, causing a range of autonomic and neuromuscular symptoms. ^[2]

Common tizanidine withdrawal symptoms

Tizanidine withdrawal symptoms can include autonomic, neuromuscular, and psychological effects.

Tizanidine withdrawal timeline

There are a few reports of tizanidine withdrawal. These reports indicate that withdrawal, although not common, can result in the rapid onset of serious symptoms. ^[2]

Withdrawal symptoms can emerge within 10-12 hours of the last dose. Without intervention, these symptoms can cause severe effects. As such, early recognition, followed by intervention and monitoring, is required. This can help prevent the worsening and prolonging of withdrawal symptoms, which can be reduced and reversed quickly. ^[2][4]

Withdrawal vs. Rebound spasticity

Typically, withdrawal symptoms and rebound symptoms are different outcomes of reducing or stopping a medication. Rebound symptoms refer to the return of symptoms of the original condition at a greater severity than they appeared prior to treatment. With tizanidine, however, both withdrawal and rebound symptoms are essentially the same. ^[4]

Tizanidine acts by blocking mechanisms in the CNS, and when the medication is stopped, these mechanisms rebound with a surge of activity. This causes a peak in catecholamine and adrenaline, which causes the onset of rebound symptoms, including hypertension, increased pulse rate, and spasticity. ^[2][4]

Risks of stopping tizanidine suddenly

Although rare, stopping tizanidine suddenly can increase the likelihood and severity of withdrawal symptoms. These symptoms can be dangerous and may require professional intervention to manage effectively and prevent severe consequences. As such, it is always advisable to reduce the dose gradually, with guidance and monitoring from a medical professional throughout. ^[2][3]

High-risk factors

Factors that can increase the risk and severity of withdrawal symptoms include: ^[2][5]

• Taking high doses of more than 20 mg per day.
• Using tizanidine for a prolonged period, of nine weeks or more.
• Using narcotic medications alongside tizanidine.
• Suddenly stopping the medication (rare on standard doses).

How you can safely taper off tizanidine

When stopping tizanidine treatment, it may be recommended to reduce the dose gradually before complete discontinuation. A doctor can advise about a safe tapering schedule, which may vary depending on the individual and the duration and amount of treatment.

A slow taper will help reduce the risk of withdrawal symptoms as it allows the body time to adjust to the changes in medication. Additionally, it ensures that any withdrawal symptoms that emerge can be managed effectively and prevented from worsening. 

The FDA recommends reductions of 2 - 4 mg per day. For example, someone taking 2 mg of tizanidine every eight hours might involve 2 mg reductions every day, starting with 2 mg every 12 hours, followed by 2 mg once daily, and finally complete cessation. Tapering can be done more slowly if needed, based on individual circumstances. ^[2]

If withdrawal symptoms emerge, medical treatment can be used to help manage and reduce their impact. For example, beta-blockers such as propranolol can be used to help manage high blood pressure, acetaminophen can be used to reduce high temperature, and benzodiazepines can be used to reduce anxiety symptoms. ^[2][4]

It is often necessary to restart a low dose of tizanidine, followed by commencing a gradual tapering schedule. Restarting tizanidine can improve withdrawal symptoms immediately. ^[4]

When to seek medical help

While most people can stop immediately with no side effects, some people on tizanidine may not be able to come off the medication without support from their prescribing physician. A medical professional will provide advice and guidance on tizanidine tapering, ensuring that there are regular reviews and monitoring of withdrawal symptoms. 

If someone reduces or stops using tizanidine, particularly if they have stopped abruptly, they should seek medical advice to ensure that they do not experience severe withdrawal or rebound symptoms. If severe or concerning symptoms emerge during the cessation process, medical assistance should be sought immediately.