Flexeril (cyclobenzaprine): How to Safely Use This Muscle Relaxant
Lower Back & Neck Pain: It's All Too Common
Chances are that you've pulled your lower back, strained your neck or twisted some other distant muscle in your body at one time or another - most of us have. If you sit at a desk daily, you may be all too familiar with this pain. Acute muscle injuries often result in a painful, constant spasm and interrupt work, daily activities, and especially sleep.
Luckily, over time, most of these acute injuries heal on their own and life goes on. But how do we survive until the pain subsides? Here, we'll review Flexeril, one option that might help in the short-term. The generic name for Flexeril is cyclobenzaprine, a frequently prescribed skeletal muscle relaxant used only for a few weeks or less to help quiet the spasm and ease the pain. In fact, using Flexeril for back pain is one of its most common uses.
What is Flexeril (cyclobenzaprine) Used For?
Flexeril (cyclobenzaprine) is a muscle relaxant used in addition to rest and physical therapy for short-term relief of muscle spasm associated with acute, painful musculoskeletal conditions. It is structurally related to the tricyclic antidepressants.
The Flexeril mechanism of action is to block nerve impulses that you recognize as pain. Cyclobenzaprine is often combined with over-the-counter (OTC) pain medications like acetaminophen (Tylenol), or anti-inflammatory NSAIDs like ibuprofen (Advil, Motrin) or naproxen (Aleve). Treatment usually lasts no more than 2 to 3 weeks.
What Strength Does Flexeril Come In?
There are two different forms of cyclobenzaprine: immediate-release tablets and extended-release capsules.
- The generic immediate-release cyclobenzaprine tablets come in a 5, 7.5, and 10 milligram (mg) strength. You may find that the 7.5 mg tablet is more expensive; it may save you money to split the 5 mg tablet in half to achieve a 7.5 mg dose (a 5 mg tablet + 2.5 mg). Ask your pharmacist about this option.
- The extended-release form of cyclobenzaprine, which has a brand name of Amrix, comes as a capsule. There is no generic form of Amrix yet, which means it will be much more expensive at the pharmacy. Amrix comes in a 15 and 30 mg strength. Be sure to check with your insurance if you receive a prescription for Amrix to see if it is covered; in 2015 many insurance companies stopped paying for this brand.
What about Flexeril price? Most strengths of generic cyclobenzaprine are very affordable, typically costing about $6-$10 for a bottle of 30 tablets. The brand Flexeril is no longer available in the U.S., but your doctor and many consumers may still say "Flexeril" because this brand name of cyclobenzaprine is so well-known.
Cyclobenzaprine is used in addition to rest and physical therapy, often with NSAIDs, and treatment duration usually does not to exceed 2 to 3 weeks.
Flexeril Side Effects
Side effects with cyclobenzaprine can be frequent, bothersome, and sometimes dangerous. Flexeril can impair your thinking or how quickly you can react. Don't drive or do any dangerous activity. Also, avoid combining Flexeril and alcohol which can worsen these side effects.
- Drowsiness, fatigue and sedation (up to 40%) is the most common side effect; do not drive or drink alcohol while taking this medication and always check for drug interactions.
- Dizziness (11%) and confusion (1-3%) might increase the risk for a fall, especially in the elderly.
- Dry mouth (30%) and blurred vision (1-3%)
- Headache (1-5%)
- Constipation (1-3%)
Be sure to review the information that comes with your prescription to understand all of the side effects.
How Does Flexeril Work?
Acute muscle spasms in the neck or back can be very painful. However, over time the pain should lessen. It is thought Flexeril (cyclobenzaprine), a centrally-acting muscle relaxant, boosts levels of norepinephrine and binds to serotonin receptors in the brain to reduce spasm.
You can determine how well your therapy is working based on your relief of muscle spasm and pain, decreasing tenderness, and increased ability to move around more easily. Muscle relaxants like cyclobenzaprine are usually used with a combination of rest, ice and/or heat, physical therapy, OTC pain relievers -- and time. You might like to join the Drugs.com Muscle Spasm support group.
Laying in bed and lack of activity may actually be worse for low back pain or other types of muscle pain and may increase your time to full recovery. Ask your doctor how you should approach your exercise and movement as you heal from your muscle strain. Two or three sessions of physical therapy, and at-home exercises may speed recovery. Yoga and meditation have been shown to be helpful for some patients, too. If you don't start to feel relief in a week or two, contact your doctor.
Flexeril Contraindications & Warnings
There may be reasons why you shouldn't use cyclobenzaprine at all.
Many skeletal muscle relaxants like Flexeril (cyclobenzaprine) can cause "anticholinergic" side effects. Anticholinergic activity blocks the action of the neurotransmitter acetylcholine and can lead to wide range of side effects. Because of this, cyclobenzaprine should be used cautiously if you have certain forms of glaucoma and high blood pressure in the eye, urinary frequency/hesitancy, or if you take other medications that also have anticholinergic effects. If you aren't sure if your medicines have anticholinergic effects, be sure to ask your pharmacist.
You should NOT use cyclobenzaprine during or within 14 days of taking a monoamine oxidase inhibitor (MAOI). MAOIs are used for depression or Parkinson's disease, and include agents such as:
Also tell your doctor if you have any thyroid gland or heart problems.
Effects of Flexeril in the Elderly
Flexeril (cyclobenzaprine) use in individuals older than 65 should be avoided in most circumstances as there is a higher risk for dangerous side effects.
Experts have developed the Beers Criteria, a set of guidelines that lists medications to avoid in the elderly. Cyclobenzaprine, an anticholinergic agent, is listed in the Beers Criteria as a potentially inappropriate medication for the elderly 65 years and older.
In general, muscle relaxants like cyclobenzaprine are poorly tolerated in older patients due to anticholinergic effects which can lead to a high risk of drowsiness, confusion, dizziness, and sedation, and an elevated risk for falls, possibly leading to bone fractures.
Serotonin Syndrome & Flexeril Drug Interactions
A potentially serious and life-threatening, but uncommon, side effect with cyclobenzaprine is known as Serotonin Syndrome. Serotonin syndrome may result in behavioral changes like agitation, confusion, seizures or hallucinations, high blood pressure, excessive sweating, muscle tremors or stiffness, and stomach problems like nausea, vomiting, or diarrhea. Drug interactions with cyclobenzaprine can boost this risk, too, so always have a pharmacist run a drug interaction screen. Common drugs that could increase this risk include:
Lower Back Pain Treatment
Lower back pain is one of the most common ailments that doctors see in the U.S. However, studies have shown that short-term use of opioid pain killers like hydrocodone or oxycodone is no more effective than using an NSAID like ibuprofen or naproxen alone. Therefore, many doctors are reluctant to prescribe opioids for back pain due to addiction risk and lack of any real added effectiveness over an NSAID. Muscle relaxants, in this one study, were also not shown to add benefit over NSAIDs alone.
However, for some patients, a muscle relaxant plus an NSAID may help to take the edge off of the pain in the short-run and allow for some much needed sleep. Since drowsiness is a common side effect with muscle relaxants, some patients may prefer to use the anti-inflammatory NSAIDs like ibuprofen or naproxen in the daytime, and add the muscle relaxant just at bedtime.
Flexeril for Fibromyalgia
Cyclobenzaprine may be used "off-label" for fibromyalgia, meaning it may be prescribed by your doctor for a generally accepted use not specifically approved by the FDA or listed in package labeling. For fibromyalgia, cyclobenzaprine has been shown to help with sleep and pain for some patients, but not provide relief for fatigue or tender points.
"Off-label" uses for Flexeril (cyclobenzaprine) include:
Clinical Trials: New Uses for Cyclobenzaprine
A sublingual (under the tongue) form of cyclobenzaprine known as TNX-102 SL (cyclobenzaprine HCl sublingual tablets) is under investigation for the treatment of Post Traumatic Stress Disorder (PSTD), including those with military-related PTSD.
In December 2016, the FDA granted Breakthrough Therapy designation to TNX-102 SL, which is anticipated to move into Phase 3 studies in the first quarter of 2017. TNX-102 SL is being developed by Tonix Pharmaceuticals.
List of Muscle Relaxers
In addition to cyclobenzaprine, many other muscle relaxant-type drugs are available:
- baclofen (Lioresal)
- carisoprodol (Soma)
- chlorzoxazone (Lorzone)
- dantrolene (Dantrium)
- diazepam (Valium)
- metaxalone (Skelaxin)
- methocarbamol (Robaxin)
- orphenadrine ER (Norflex)
- tizanidine (Zanaflex)
In the US, diazepam (classified as a benzodiazepine but also used as a muscle relaxant), and carisoprodol are both scheduled as controlled substances and can become habit-forming.
All options are available as cost-saving generics in the US.
Finished: Flexeril (cyclobenzaprine): How to Safely Use This Muscle Relaxant
- Tonix Pharmaceuticals’ PTSD Phase 3-Ready Drug Candidate, TNX-102 SL, Granted Breakthrough Therapy Designation by the FDA. Drugs.com. Dec. 19, 2016. Accessed January 20, 2017 at https://www.drugs.com/clinical_trials/tonix-pharmaceuticals-ptsd-phase-3-ready-candidate-tnx-102-sl-granted-breakthrough-therapy-17289.html
- Prescription Naproxen as Good as Narcotic Painkillers for Low Back Pain: Study. Drugs.com. Oct 20, 2015. Accessed Jan. 20, 2017 at https://www.drugs.com/news/naproxen-good-narcotic-painkillers-low-back-pain-study-58698.html
- Cyclobenzaprine. Pharmacology. Epocrates.com. Accessed Jan 20, 2017 at http://www.epocrates.com.
- Flexeril product labeling. McNeil Consumer & Specialty Pharmaceuticals. Accessed January 20, 2017 at https://www.drugs.com/pro/flexeril.html
- GoodRx. Cyclobenzaprine; Flexeril. Accessed January 22, 2017 at https://www.goodrx.com/.