Muscle cramps

Top tips:

  1. Muscle cramps are common in patients with cirrhosis and can have a significant impact on quality of life (QoL)
  2. The underlying cause of muscle cramps is poorly understood. Potential risk factors include ascites, lower mean arterial pressure, and altered energy metabolism
  3. Identify if there are any modifiable factors that can be treated.
  4. If symptoms are affecting quality of life and function, a trial of pharmacological therapy is reasonable. At this time, pharmacological management recommendations are based on small trials and expert opinion
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Check out the bottom of the page for a short video from Dr. Patel!

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Step 1: Assess for and address any other potential treatable causes

There are many non-cirrhosis and cirrhosis causes of muscle cramps.
If non-cirrhosis causes are suspected, consider specialist referral as appropriate.

Characteristics of cirrhosis related muscle cramps:
chronic, involuntary, brief, sudden, intense, worse at night.

 

Potential contributing factors include
  • Restless legs syndrome (irresistible urge to move or shake the legs)
  • Periodic limb movements,
  • Dystonia,
  • Neurologic disorders, peripheral neuropathy (numbness, tingling),
  • Myalgias, myositis
  • Peripheral vascular disease/claudication, ischemia (deep aching pain, weakness, elevated serum CK), venous insufficiency
  • Motor neuron disorders (abnormal EMG)
  • Anemia
  • Raynaud’s syndrome
  • Opioid withdrawal
Muscle cramps may also be due to complications of cirrhosis
  • Electrolyte abnormalities: Check potassium, sodium, calcium, magnesium, HCO3, TSH levels, and replete if low.
  • Acid-base disturbances
  • Worsening liver or renal function
Step 2: Consider non-pharmacological management

Consider non-pharmacological management in all patients where symptoms significantly impact a patient’s quality of life and function.

<strong>Recommend practical non-pharmacological therapies as a starting point</strong>
  • Exercise therapy
  • Passive stretching
  • Deep tissue massage
Step 3: If symptoms persist, consider Pharmacological management

Caution: Recommendations are based on small trials and expert opinion

Medication: Recommended Dose Additional information
Branched chain amino acids 4 grams PO TID
  • Several small studies show benefit (Vidot 2014)
  • Taste and cost may limit use
  • May be purchased from supplement stores
Baclofen 10mg PO daily
Increase by 10 mg PO weekly until at 30 mg PO daily
  • RCT of 100 patients associated with a disappearance of cramps in 72% of patients after 3 months of treatment, without significant side effects (Elfert 2016)
  • Adverse effects may include somnolence and nausea, urinary retention
Taurine 3 grams PO daily
  • Small, non-randomized studies report benefit
  • May be purchased from supplement stores
IV Albumin therapy IV 100cc of 25% q weekly
  • Limited data to support this. A single, small RCT showed improvement that stopped once infusions were discontinued (Angeli 1996)

  • Resource heavy
NOTE: Quinine sulfate (200-300 mg qhs) is not routinely available or recommended. It has been associated with arrhythmias and thrombocytopenia. Tonic water, although often suggested by clinicians only has 83 mg of quinine per liter.

Special considerations at End-of-life (last few days to weeks)
Special considerations at End of Life (last few days to weeks)
  • As the patient’s condition deteriorates, muscle cramping may worsen and not be amenable to the above therapies.
  • If muscle cramps are causing significant pain, pain medication may be required (LINK to PAIN CCAB).
  • Discuss with the patient and family that pharmacological therapy may increase drowsiness
  • Consider Palliative Care consultation for refractory symptoms.

 Introducing Dr. Patel

Video 1 - The top tips that may be useful for you to know about managing muscle cramps

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon

Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages. 

Helpful Links:
  1. Goals of care: https://www.albertahealthservices.ca/frm-103547.pdf
  2. Exercise Therapy: http://cirrhosiscare.ca/healthy-living-provider/exercise-therapy-hcp/
  3. Pain Control: http://cirrhosiscare.ca/symptom-management-provider/pain-hcp/
References:
  1. Abd-Elsalam Sherief et al. United European Gastroenterology Journal 2018;6(3) 422-427.
  2. Abd-Elsalam Sherief et al. European Journal of Gastroenterology and Hepatology 2018; 31:499-502.
  3. Abd-Elsalam S, Arafa M, Elkadeem M, Elfert A, Soliman S, Elkhalawany W, Badawi R. Randomized-controlled trial of methocarbamol as a novel treatment for muscle cramps in cirrhotic patients. Eur J Gastroenterol Hepatol. 2019 Apr;31(4):499-502. doi: 10.1097/MEG.0000000000001310. PMID: 30444744.
  4. Angeli P, Albino G, Carraro P, Dalla Pria M, Merkel C, Caregaro L, De Bei E, Bortoluzzi A, Plebani M, Gatta A. Cirrhosis and muscle cramps: evidence of a causal relationship. Hepatology. 1996 Feb;23(2):264-73. doi: 10.1002/hep.510230211. PMID: 8591851.
  5. Elfert AA, Abo Ali L, Soliman S, Zakaria S, Shehab El-Din I, Elkhalawany W, et al. Randomized placebo-controlled study of baclofen in the treatment of muscle cramps in patients with liver cirrhosis. Eur J Gastroenterol Hepatol 2016;28:1280-1284. PMID: 27467714
  6. Henry ZH, Northup PG. Baclofen for the treatment of muscle cramps in patients with cirrhosis: A new alternative. Hepatology. 2016 Aug;64(2):695-6. doi: 10.1002/hep.27988. Epub 2015 Aug 22. PMID: 26175073.
  7. Kugelmas M. Preliminary observation: oral zinc sulfate replacement is effective in treating muscle cramps in cirrhotic patients. J Am Coll Nutr. 2000 Feb;19(1):13-5. doi: 10.1080/07315724.2000.10718908. PMID: 10682870.
  8. Mehta SS, Fallon MB. Muscle cramps in liver disease. Clin Gastroenterol Hepatol. 2013 Nov;11(11):1385-91; quiz e80. doi: 10.1016/j.cgh.2013.03.017. Epub 2013 Mar 28. PMID: 23542334.
  9. Peng JK, Hepgul N, Higginson IJ, Gao W. Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis. Palliat Med. 2019 Jan;33(1):24-36. doi: 10.1177/0269216318807051. Epub 2018 Oct 22. PMID: 30345878; PMCID: PMC6291907.
  10. Vidot H, Carey S, Allman-Farinelli M, Shackel N. Systematic review: the treatment of muscle cramps in patients with cirrhosis. Aliment Pharmacol Ther. 2014 Aug;40(3):221-32. doi: 10.1111/apt.12827. Epub 2014 Jun 18. PMID: 24942957.
We gratefully acknowledge the Physician Learning Program for their design assistance.

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