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Dr. Andrew Rynne

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Can benzodiazepines be used as a muscle relaxant?

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Dr. Olsi Taka

Neurologist

Practicing since :2004

Answered : 3044 Questions

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Posted on Fri, 11 May 2018 in Brain and Spine
Question: Dear Doctor,

I’m a single mother with an eight year old daughter living in Toronto Canada. I’ve been suffering from the non-stop heavy symptoms of feeling something “prickly” stuck in my lower throat/upper esophagus area, due to the esophageal spasm caused by mild reflux, making me couldn’t lead normal life at all.

I used to catch this illness and I recovered by taking PPI and Diazepam. I then enjoyed a whole year of happy life from Apr 2015 to Mar 2016. Unfortunately, it recurred triggered by a stomach flu in Mar 2016. It triggered my reflux and then esophageal spasm that gave me that non-stop heavy intolerable symptoms again of feeling something “prickly” stuck in my lower throat/upper esophagus area, making me can’t lead normal life again. In fact when it recurred, I took Diazepam 5mg b.i.d. with the remaining stocks and the symptoms disappeared immediately. However, when I went to see the psychiatrist who prescribed me Diazepam for the first time, he didn’t want to prescribe me this medication and referred me to a GI doctor saying that this is a GI problem not a psychiatric problem. The GI doctor asked me to take nifedipine for 10 weeks that made me feel even worse. I lost more than 5kg body weight in several months and became very weak. I’ve also tried seeing some other specialist doctors but none of them worked yet until now.

Besides, I took Diazepam 10mg b.i.d. starting from mid May 2016 until Dec 6 2017. Because of the tolerance partly due to the delay to take it after the recurrence, it can’t control my symptoms anymore this time. It makes me feel really upset and hopeless. A psychiatrist changed me from Diazepam to another medication named clonazepam 0.5mg b.i.d. from the evening of Dec 6 2017 and I don’t feel it work yet.

I’ve done endoscopy+flip test, esophageal manometry and off-PPI 24hr PH monitor by professional GI. It is normal of endoscopy+flip test. The esophageal manometry shows that I have serious esophageal spasm and the esophageal sphincter contract too much. The off-PPI 24hr PH monitor shows that I have mild reflux while I can’t feel any symptoms. This may be the silent reflux that keeps irritating my esophagus with small amount of acid so that I'm taking PPI.

By doing some study, it seems that the medications of Benzodiazepine class will work for me. This class of medications has several functions with smooth muscle relaxant as one of them. I’ve checked and found that there are 13 medications available in Canada of Benzodiazepine class (as attached file). I want to ask which one has better effect as smooth muscle relaxant? I’m thinking it may help me if switching to the proper one to well control my symptoms again. So long as it works, I can gradually quit it as last time and don’t think that I would be addictive to it.

Besides, I’ve learned something about ANS and my problem may be the caused by the disorder of sympathetic system making the sphincter to contract and parasympathetic system making the sphincter to relax.

To be honest, it’s quite suffering but I can’t give up since my daughter needs and loves me so much.

Thanks a lot!
XXXXXXX
doctor
Answered by Dr. Olsi Taka 3 hours later
Brief Answer:
Diazepam and lorazepam, but benzos not the best solution.

Detailed Answer:
I read your question carefully and I understand your concern.

If I were to pick a benzodiazepine for its muscle relaxant properties lorazepam and diazepam would be the first choices. However they are similar in their properties and way they act, they differ only in onset and duration of their effects. I wouldn't be that supportive of their use though, I understand that you've been able to wean off in the past but still there is the dependence risk as well as tolerance build-up. You might perhaps try also other non-benzodiazepine muscle relaxants such as cyclobenzaprine or tizanidine.

I would like to make some additional remarks. First regarding the other medications you mention, it is unclear whether you currently are taking all those drugs you mention. I hope not all of them at this moment as I see 4 antidepressants there. Remember that some of them may cause dry mouth which may also contribute to that throat sensation.

Also I wonder whether calcium and parathyroid hormone levels have been checked. That is because you mention thyroidectomy which may lead to damage of parathyroid glands and low calcium levels. Low calcium levels may cause muscle spasms. Perhaps it's already been checked, but I thought I'd mention it to make sure.

I remain at your disposal for other questions.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 1 hour later
Dear Dr. Taka,

Thanks for your reply, remarks and advices. Currently I'm only taking PPI and just started changing from diazepam to clonazepam since I've already have tolerance on diazepam after the recurrence, but I don't feel that clonazepam will work.

No worry. Those antidepressants are the medications I used to try three years ago only for a short period as per doctor's instructions and none of them worked a little bit to reduce my symptoms. I don't think antidepressants can help solve my problem.

May I ask if tizanidine will lower my blood pressure? I was asked to take nifedipine for 10 weeks by a GI doctor here in Jun-Aug 2016. But it didn't work to my symptoms and gave me strong fatigue and lowered by my blood pressure etc. Furthermore, it affected the absorption of levothyroxine that I need to take daily making me have hypothyroidism.

I'll see if I can get cyclobenzaprine as per your advice, also to test parathyroid hormone levels. I'm OK in calcium level.

Do you think I should try balcofen?

My case is really rare in Canada. I'm stuck and kind of pushed in between doctors in different specialties here that I have to think ways to see what can be done. I was once refused by a neurologist to see me with the reason that he don't think my problem is related with neurology. I think my problem is in fact related with several medical specialties.

My expectation is just to control this bothering symptoms to the extent that I can lead normal life. No need to make it totally disappear. While, it seems quite hard to achieve.

I'm open to listening to more of your advice.

Great thanks, XXXXXXX
doctor
Answered by Dr. Olsi Taka 7 hours later
Brief Answer:
Read below

Detailed Answer:
Thank you for the additional information. I must say I can’t blame the doctors for prescribing antidepressants as such symptoms are often influenced by anxiety, I probably would’ve started with an antidepressant as well (I hope that the short period you refer to was at least a month, their effect needs several weeks).
Regarding your question on effect of tizanidine on blood pressure, it can lower blood pressure in some patients, though not as much as Nifedipine.
Other options which I didn’t include in my first answer would be also nitrates and hydralazine which are generally used for other purposes but they also act as effective smooth muscle relaxants. There is the possibility of lowering blood pressure with them as well though (blood vessel walls are regulated by smooth muscle).

Let me know if I can further assist you.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 15 hours later
Dear Dr. Taka,

I got panic when I learned that I caught thyroid cancer and lost my judgement. Therefore, although the surgery is good, I did a lot of wrong things after the surgery hurting my digestive system. The endoscopy done 3 months after the surgery (in Aug 2014) shows that I had local erosion at gastric angles, congestion & erosion in gastric antrum and esophagitis caused by reflux(G1 period) while my digestive system is healthy before the surgery. Later did another endoscopy in Nov 2014 and everything looks normal then.

Regarding the antidepressants I used to take:
Yes. A good GI doctor with rich clinical experiences in China told me that digestive system illness can be highly related with anxiety. I took deanxit for several months to treat anxiety together with PPI to treat reflux upon his instructions. An experienced psychiatrist in China asked me to take remeron for 6 months to help me calm down but he said that it couldn’t help control my symptoms. His judgement was that my depression was secondary and it would be gone once my physical symptoms disappear by proper medical treatment. After stopping deanxit and remeron, I was instructed to try other antidepressants for a couple of months by psychiatrists in Toronto.

I don’t blame any doctors since it is not an easy occupation especially when dealing with my rare and complicated situation.

Do you know the medication of estazolam? It is benzos and available in US, UK and many other countries but not in Canada. Both the above mentioned GI doctor in China and a good GI doctor in Albania asked me to change diazepam to estazolam 1mg b.i.d. They think estazolam should work in my situation and advised me to take it for 4-8 weeks in total upon the recurrence of my illness. May I know your advice about estazolam?

Besides, do you think that my problem is related with the disorder of sympathetic system and parasympathetic system?

Your opinions broaden my views and ways to treat my illness that are really helpful. Your reminder to test calcium and parathyroid hormone level are useful since I haven’t checked them for 3 years. I have an appointment with my family doctor in coming Monday. She is a good doctor and we’re now stuck about the next steps to treat my illness. Your input is valuable that I can discuss with her to see next steps.

Thanks for keep replying me and keeping it open to further assist me.
XXXXXXX
doctor
Answered by Dr. Olsi Taka 11 hours later
Brief Answer:
Read below

Detailed Answer:
Hello again and thank you for the update.
If antidepressant has been taken for 2 months then it is an adequate trial, if any benefit they should’ve been visible.
As for estazolam, it is a benzodiazepine which I know of but I confess haven’t tried it for your condition since officially it is approved only for the treatment of insomnia. In theory it shouldn’t offer any additional benefits. It is an intermediate acting benzodiazepine, similar to lorazepam which I mentioned, so I am not aware of any additional benefits for your case. That doesn’t mean it won’t work, perhaps the doctors who recommended it have personal experiences in patients similar to you, but since I haven’t used it for that purpose and do not find any literature on that regard can’t endorse it myself.
As for autonomous system (sympathetic/parasympathetic) disorders, of course they may affect digestive system. However, they happen usually in the setting of other conditions such as diabetic neuropathy, Parkinson’s etc, rarely alone. Also the fact you got better for some time wouldn’t support it, as primary autonomous system disorders are usually progressive. They also have usually other symptoms such as blood pressure issues, sweating abnormalities, bowel movement issues etc. So possible as rare syndromes are often reported in individual patients, but unlikely.

Wishing you good health.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 3 hours later
Hello Dr. Taka,

Thanks for your detailed reply.

My friend just found a quite relevant article written by a doctor who is also a professor in University of Southern California dated Apr 2017. In this article, she says that benzo is not the first choice to treat muscle spasm that is the same opinion as you. She mentions that there are 4 medications that are the first choices to treat muscle spasm in neck and back that are carisoprodol, cyclobezaprine, methocarbamol, metaxalone.

FYI here is the link: https://www.goodrx.com/blog/which-muscle-relaxants-are-best-for-neck-and-back-pain/ but I can't log into it now(probably the website is in maintenance).

Apart from cyclobezaprine that you've mentioned before, do you know the other three medications and any advice about them?

Besides, Dr. Pandolphino in Northwestern Memorial Hospital who is an expert in treating esophageal disorder used to ask me if I've ever tried the medications of Viagra or Cialis. Do you know this two medications and any advice about them?

Currently, I'm taking levothyroxine, PPI and clorazepam. For levothyroxine and PPI, they are the must. I don't think clorazepam is helping me and feels that it even makes my symptoms worse than taking diazepam. Anyway, I would try not to go back to diazepam since I've been taking it so long without much effect any more and want to quit it in a proper way by seeking help from the psychiatrist here in Toronto.

I'm thinking that maybe my problem is not as complicated as I think. If I can find the right medication, it may work soon and I can lead normal life again. Need to think out of the box of my first time recovery process with the professional help of doctors like you.

Besides, which medication do you think I should try first? I'm thinking cyclobezaprine. How much dosage do you recommend and time to take it everyday? How long do you think I should try to see if it works? Doctors in which specialty would prescribe this medication? What should I do with clorazepam if start taking cyclobezaprine?

May I ask if you have any advice on the priority of the medications that I should try and what specialty doctor may prescribe them respectively? Here is the list that I summarize:
- cyclobezaprine
- carisoprodol
- methocarbamol
- metaxalone
- tizanidine
- nitrates
- hydralazine
- viagra
- cialis

Sorry I'm asking you too many questions.

My sincere thanks and best wishes for you, XXXXXXX
doctor
Answered by Dr. Olsi Taka 5 hours later
Brief Answer:
Read below.

Detailed Answer:
I read the article your friend mentioned you. While it confirms what I said regarding benzodiazepines I wouldn't say that your case is a little different. That is because most muscle relaxants around (including cyclobenzaprine and tizanidine I mentioned, as well as carisoprodol and methocarbamol mentioned in that article) have mainly been studies and used in skeletal muscle spasms, but are less proven in esophageal spasms, so success is less guaranteed. In addition all of them have some side effects such as drowsiness and dependence so they are not recommended for long term use, usually only for 2-3 weeks.
Cyclobenzaprine is the most widely used, regarding dosage it is 5 mg tablets 3 times daily.
If not effective I would not go to the other 4 in your list as they have similar effects but would try another class such as a nitrate.
Viagra and cialis would be the next option (belong to same class). While I know them well, I haven't tried them for this indication, usually used for erectile dysfunction, but they are cited to be effective by several studies.

I hope to have been of help.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 41 hours later
Dear Dr. Taka,

Thanks a lot for your explanations. It's very clear.

I've seen my family doctor yesterday. She thinks that I have serious anxiety which is the key reason of my current symptoms and doesn't think that muscle relaxant medications would help reduce my symptoms. I agree that I now have anxiety due to the long time suffering from the symptoms without solution while disagree that muscle relaxant medications wouldn't help my symptoms. The esophageal manometry test reports shows clearly that I have esophageal spasm and I've done this test in both Toronto and at the esophageal centre of Northwestern Memorial Hospital in XXXXXXX where the facility and techniques are more advanced in Toronto.

Thanks for your advice that my family doctor prescribed me with the medication of cyclobezaprine for trial. She asked to take 10mg b.i.d. to see the result and an experienced pharmacist instructed me to take it right after meal since it may hurt the stomach.

Besides, my family doctor thinks that the change from diazepam 10mg b.i.d. to clorazepam 0.5mg b.i.d. as instructed by a psychiatrist is not appropriate worsening my anxiety. She asked to continue clorazepam 0.5mg b.i.d. for 10-15 more days and then reduce it to 0.5mg once a day for one month so that I can stop benzos. I agree with her regarding this.

She said that she would try to refer me to a very good psychiatrist. Since it's not easy to get an appointment from a really good doctor here in Canada, she said that she would prescribe me a kind of medication that would make my whole body relaxed and my symptoms should disappear then if I can't be arranged to see that psychiatrist one month later. She is very busy spending a lot of time on me yesterday so I didn't get the name of that medication she mentioned. She said it's not antidepressant and used a strange word to me that I think it belong to another professional and advanced field of that medication. She is a very responsible doctor and I learned from others that she has PHD in Europe and then post-doctor in University of Toronto.

All the best, XXXXXXX

doctor
Answered by Dr. Olsi Taka 7 hours later
Brief Answer:
Read below

Detailed Answer:
Thank you again in keeping in touch.

Whether she's right or not your family doctor seems like a sensible and professional doctor. As I said before I would be inclined to blame symptoms on anxiety as well. What doesn't fit is the fact that you've tried several antidepressants without effect (antidepressants are first choice anxiety medication). The manometry tests you mention are another contradicting data. However symptoms may be due to a combination of more than one cause so since you yourself feel anxiety is an issue it should be addressed, so it is good she's addressing you to a good psychiatrist.
As for the medication she's going to prescribe to you it's tough to make comments without knowing the name. At times antiepileptics are used to treat anxiety. Buspiron is another alternative as well as antipsychotics. When you get the prescription I'd appreciate you letting me know the name.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Olsi Taka 47 hours later
Dear Dr. Taka,

Thanks for your feedback and sorry for my late reply. I'm really suffering from the symptoms and the recent change from diazepam 10mg b.i.d. to clonazepam 0.5mg b.i.d. makes my physical symptoms worse. In fact this decision is made by a psychiatrist when I went to hospital emergency on Dec 6th 2017 in a rush who has many years of experiences as a certificate psychiatrist. At that time, he was reluctant to see me and only talked to me for 5 minutes kept interrupting me without even asking my symptoms. Anyway, I don't blame any doctor that is off my goal although I do hope doctors can be more responsible and open-minded. I myself don't have the courage to be a doctor since this occupation decides the happiness and even the life of others.

Back to the topic, I've consulted with Dr. Pandolfino in Northwestern Memorial Hospital in XXXXXXX who saw me one year ago about the medications of cyclobenzaprine(flexeri), carisoprodol(somadril), methocarbamol(Robaxin), metaxalone(skelaxin), balcofen and tizanidine. His reply is that "The medications you listed are mainly for skeletal muscle -- but it is the right idea." Anyway, I will start to try cyclobenzaprine from this evening to see if it works. It shouldn't take long to know the results, say 2 weeks, and I will stop it if it does not work since there is no dependence issue for this medication.

I myself think that my current symptoms are mainly due to the physical illness of esophageal spasm caused by mild reflux as a result of my inappropriate post surgery behaviors of thyroidectomy in May 2014. It further causes my mental issues of anxiety feeling hopeless due to the long lasting diagnosis process, the recurrence of symptoms and the symptoms can't be well controlled for such a long time making me can't lead normal life. The mental issue further worsens my symptoms.

Sure I'm willing to let you know the name of that medication once I got it. While, it sounds like an antipsychotics as per my family doctor said to me upon seeing your reply. She also mentioned that she would refer me to a neurologist in the meanwhile.

FYI I used to be put on paroxetine 20mg per day on Feb 2015 by my previous family doctor. I insisted for 10 days with various other heavy symptoms that I remembered that I couldn't sleep at night since my heart kept vibrating and I was sweating, feeling strong nausea etc. and had to go to hospital emergency finally.

I don't know how to contact you in the future on this website after this consultation. Could you please give me your email address if you don't mind. I would for sure update you about the name of that medication and my progress so long as I could. My email is YYYY@YYYY . I'm really lucky to get your valuable analysis and advice.

Great thanks and best wishes, XXXXXXX
doctor
Answered by Dr. Olsi Taka 12 hours later
Brief Answer:
Read below

Detailed Answer:
Hello XXXXXXX

My email address is YYYY@YYYY .

Hope you feel better soon.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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