Muscle Relaxant Use Among Hemodialysis Patients: Prevalence, Clinical Indications, and Adverse Outcomes

Am J Kidney Dis. 2019 Apr;73(4):525-532. doi: 10.1053/j.ajkd.2018.11.008. Epub 2019 Jan 11.


Rationale & objective: Muscle relaxants are often used to treat musculoskeletal pain or cramping, which are commonly experienced by hemodialysis patients. However, the extent to which muscle relaxants are prescribed in this population and the risks associated with their use have not been characterized.

Study design: Observational cohort study.

Setting & participants: 140,899 Medicare-covered adults receiving hemodialysis in 2011, identified in the US Renal Data System.

Exposure: Time-varying muscle relaxant exposure.

Outcomes: Primary outcomes were time to first emergency department visit or hospitalization for altered mental status, fall, or fracture. Secondary outcomes were death and composites of death with each of the primary outcomes.

Analytical approach: Multivariable Cox regression analysis.

Results: 10% of patients received muscle relaxants in 2011. 11%, 6%, 3%, and 13% had an episode of altered mental status, fall, fracture, and death, respectively. Muscle relaxant use was associated with higher risk for altered mental status (HR, 1.39; 95% CI, 1.29-1.51) and fall (HR, 1.18; 95% CI, 1.05-1.33) compared to no use. Muscle relaxant use was not statistically significantly associated with higher risk for fracture (HR, 1.17; 95% CI, 0.98-1.39). Muscle relaxant use was associated with lower hazard of death (HR, 0.85; 95% CI, 0.76-0.94). However, hazards were higher for altered mental status or death (HR, 1.17; 95% CI, 1.10-1.25), fall or death (HR, 1.14; 95% CI, 1.06-1.22), and fracture or death (HR, 1.10; 95% CI, 1.01-1.20).

Limitations: A causal association between muscle relaxant use and outcomes cannot be inferred, and residual confounding cannot be excluded. Exposure and outcomes were ascertained using administrative claims.

Conclusions: Muscle relaxant use was common in hemodialysis patients and associated with altered mental status and falls. We could not rule out a clinically meaningful association between muscle relaxant use and fracture. The lower risk for death with muscle relaxants may have been the result of residual confounding. Future research to define the appropriate use of muscle relaxants in this population is warranted.

Keywords: Muscle relaxant; US Renal Data System (USRDS); altered mental status; back pain; cramps; cyclobenzaprine; drug safety; fall; fracture; hemodialysis; muscle spasticity; musculoskeletal pain; prescribing patterns.

Publication types

  • Multicenter Study
  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Accidental Falls / statistics & numerical data
  • Adolescent
  • Adult
  • Aged
  • Aged, 80 and over
  • California / epidemiology
  • Drug Prescriptions / statistics & numerical data*
  • Emergency Service, Hospital
  • Female
  • Follow-Up Studies
  • Fractures, Bone / epidemiology
  • Fractures, Bone / etiology
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Musculoskeletal Pain / drug therapy*
  • Musculoskeletal Pain / etiology
  • Neuromuscular Agents / adverse effects
  • Neuromuscular Agents / pharmacology*
  • Registries*
  • Renal Dialysis / adverse effects*
  • Retrospective Studies
  • Young Adult


  • Neuromuscular Agents