Cyclobenzaprine, brand names Amrix, Flexeril and Fexmid, is a muscle relaxer medication used to relieve skeletal musclespasms and associated pain in acute musculoskeletal conditions. It is the best-studied drug for this application, it has also been used off-label for fibromyalgia treatment. A new bedtime formulation of cyclobenzaprine is under development for the management of fibromyalgia syndrome.
After sustaining an injury, muscle spasms may occur to stabilize the affected body part and prevent further damage. They also generate pain. Cyclobenzaprine is FDA-approved to treat such muscle spasms associated with acute, painful musculoskeletal conditions. It decreases pain in the first two weeks, peaking in the first few days, but has no proven benefit after two weeks. Since no benefit is proven beyond that, therapy should not be continued long-term. It is not useful for spasticity due to neurologic conditions such as cerebral palsy.
Cyclobenzaprine has also shown effectiveness in the treatment of fibromyalgia symptoms, with a report of 4.8 patients needing treatment for each (1) patient reporting pain reduction (but no change in fatigue or tender points).
In elderly patients, cyclobenzaprine HCl may be started at a lower dose and titrated slowly upward. Cyclobenzaprine is recommended for use up to 3 weeks, but clinical efficacy has not been demonstrated beyond this point and long term use of cyclobenzaprine is not recommended. Cyclobenzaprine, however, has not been documented to cause intense physical and psychological withdrawal symptoms following discontinuation such as those which occur with its benzodiazepine, barbiturate, and carbamate alternatives, although the potential for rebound plasticity is of clinical relevance.
Meta-analysis studies have found significantly increased rates of drowsiness (38% of patients), dry mouth (24%), dizziness (10%), and adverse events of any kind in patients taking cyclobenzaprine versus placebo. Drowsiness and dry mouth appear to intensify with increasing dose.
The sedative effects of cyclobenzaprine are likely due to its antagonistic effect on histamine, serotonin, and muscarinic receptors. Agitation is a common side effect observed especially in the elderly. In general, the NCQA recommends avoiding the use of cyclobenzaprine in the elderly because of the potential for more severe side effects. There is one case report of overdose causing rhabdomyolysis (muscle breakdown). Treatment protocols and support should follow the same as for any structurally related tricyclic, such as tricyclic antidepressants.
If co-administered with opioids the dose of one or both medicines should be reduced accordingly. The patient should be monitored for excessive sedation.
Comparison to other medications
Cyclobenzaprine has been found to be non-inferior to tizanidine, orphenadrine, and carisoprodol in the treatment of acute lower back pain, although none have been proven to be effective for long term use (beyond two weeks of treatment). No differences in pain or spasm scores were noted among these agents, nor when compared to benzodiazepines. However, nonbenzodiazepine (including cyclobenzaprine) treatment was found to have a lower risk of medication abuse and continuation of use against medical advice. Side effects such as sedation and ataxia are also less pronounced with nonbenzodiazepine antispasmodics.
In a study on the treatment of musculoskeletal pain treatment with cyclobenzaprine alone or in combination with ibuprofen no significant differences in pain scores were noted among the three treatment groups. Peak benefit was found to occur on day 7 of the treatment for all groups.
Cyclobenzaprine, N,N-dimethyl-3-(dibenzo[a,d]cyclohepten-5-ylidene)propylamine, is synthesized by reacting 5H-dibenzo[a,d]cyclohepten-5-one with 3-dimethylaminopropylmagnesium chloride and subsequent dehydration of the resulting carbinol in acidic conditions into cyclobenzaprine.
Orally, cyclobenzaprine is marketed as Apo-Cyclobenzaprin, Flexeril, Fexmid and Novo-Cycloprine. It is available in generic form. A once-a-day, extended-release formulation, Amrix, is available. Cyclobenzaprine is also used by compounding pharmacies in topical creams.
Cyclobenzaprine is regulated in the U.S. for prescription use only. Though it does not fall within most governmental guidelines as a controlled substance, possession of it without a valid or current prescription may be illegal, depending upon various state and local laws.
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