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Jergova S, Hernandez M, Sagen J. Analgesic effect of recombinant GABAergic precursors releasing MVIIA in a model of peripheral nerve injury in rats. Mol Pain 2022; 18:17448069221129829. [PMID: 36113096 PMCID: PMC9513588 DOI: 10.1177/17448069221129829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Development of chronic pain has been attributed to dysfunctional GABA signaling in the
spinal cord. Direct pharmacological interventions on GABA signaling are usually not very
efficient and often accompanied by side effects due to the widespread distribution of GABA
receptors in CNS. Transplantation of GABAergic neuronal cells may restore the inhibitory
potential in the spinal cord. Grafted cells may also release additional analgesic peptides
by means of genetic engineering to further enhance the benefits of this approach.
Conopeptides are ideal candidates for recombinant expression using cell-based strategies.
The omega-conopeptide MVIIA is in clinical use for severe pain marketed as FDA approved
Prialt in the form of intrathecal injections. The goal of this study was to develop
transplantable recombinant GABAergic cells releasing conopeptide MVIIA and to evaluate the
analgesic effect of the grafts in a model of peripheral nerve injury-induced pain. We have
engineered and characterized the GABAergic progenitors expressing MVIIA. Recombinant and
nonrecombinant cells were intraspinally injected into animals after the nerve injury.
Animals were tested weekly up to 12 weeks for the presence of hypersensitivity, followed
by histochemical and biochemical analysis of the tissue. We observed beneficial effects of
the grafted cells in reducing hypersensitivity in all grafted animals, especially potent
in the recombinant group. The level of pain-related cytokines was reduced in the grafted
animals and correlation between these pain markers and actual behavior was indicated. This
study demonstrated the feasibility of recombinant cell transplantation in the management
of chronic pain.
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D'Souza RS, Barman R, Joseph A, Abd-Elsayed A. Evidence-Based Treatment of Painful Diabetic Neuropathy: a Systematic Review. Curr Pain Headache Rep 2022; 26:583-594. [PMID: 35716275 DOI: 10.1007/s11916-022-01061-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Painful diabetic neuropathy (PDN) manifests with pain typically in the distal lower extremities and can be challenging to treat. The authors appraised the literature for evidence on conservative, pharmacological, and neuromodulation treatment options for PDN. RECENT FINDINGS Intensive glycemic control with insulin in patients with type 1 diabetes may be associated with lower odds of distal symmetric polyneuropathy compared to patients who receive conventional insulin therapy. First-line pharmacologic therapy for PDN includes gabapentinoids (pregabalin and gabapentin) and duloxetine. Additional pharmacologic modalities that are approved by the Food and Drug Administration (FDA) but are considered second-line agents include tapentadol and 8% capsaicin patch, although studies have revealed modest treatment effects from these modalities. There is level I evidence on the use of dorsal column spinal cord stimulation (SCS) for treatment of PDN, delivering either a 10-kHz waveform or tonic waveform. In summary, this review provides an overview of treatment options for PDN. Furthermore, it provides updates on the level of evidence for SCS therapy in cases of PDN refractory to conventional medical therapy.
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Affiliation(s)
- Ryan S D'Souza
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ross Barman
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amira Joseph
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Alaa Abd-Elsayed
- Department of Anesthesiology and Perioperative Medicine, University of Wisconsin, Madison, WI, USA.
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Kenfield M, Zacharias N, Abd-Elsayed A. Intrathecal Drug Delivery for the Treatment of Cancer-Associated Chronic Pain in Children. Neuromodulation 2021:S1094-7159(22)00576-1. [PMID: 34520605 DOI: 10.1111/ner.13535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/27/2021] [Accepted: 08/16/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Management of refractory cancer-associated pain can be particularly challenging. Regional anesthesia is an alternative modality to treat acute and chronic refractory pain. Intrathecal (IT) drug delivery of opioids and other adjuncts has been used to treat refractory cancer-associated pain. This method has been shown to be relatively safe and effective, often associated with fewer systemic side effects when compared to oral or IV opioid administration. While intrathecal drug delivery systems (IDDS) are regularly used in the adult cancer population for the treatment of refractory, chronic pain, there is limited evidence of similar use in the pediatric setting. MATERIALS AND METHODS We performed a systematic review using conventional Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology to identify studies reporting IT drug delivery for the treatment of pediatric cancer-related pain. The primary outcome was satisfaction with analgesia categorized as "satisfactory" or "unsatisfactory." Functional benefits, previous systemic pharmaceutical interventions, previous non-IT regional interventions, indication for IT drug delivery, IT drugs used, and method of delivery were collected. RESULTS A total of 11 studies were identified, describing 16 patients with cancer-related pain treated with IT drug delivery. The average age of the cohort was 12.25 years, with ages ranging from 3 to 19 years. Most patients were adolescent (10/16). All patients had cancer diagnoses, with most patients suffering from solid tumor pain (14/16). Nearly all patients achieved satisfactory analgesia through IT drug delivery (15/16) and most reported functional benefits in addition to analgesia (13/16). Majority received IT drugs via external catheters (9/16). One severe complication of respiratory depression was reported, which resolved following naloxone administration. CONCLUSIONS There exist children with cancer whose pain is refractory to the standard approaches and may benefit from IT drug delivery. The existing data, although limited and of low tier evidence, suggest that IT drug delivery has been effective in the pediatric cancer population.
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Affiliation(s)
- Meaghan Kenfield
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Nicholas Zacharias
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Alaa Abd-Elsayed
- Anesthesiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Daya MP, Saleh AY, Astari RV. The Effect of Antinociceptive Flavonoid on Leea Indica Leaves for Orofacial Pain of Adult Zebra Fish (Danio Rerio). FOLIA MEDICA INDONESIANA 2021. [DOI: 10.20473/fmi.v57i2.17711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Pain affects millions of people and is one of the most frequent complaints in the medical office. Pain involves various behavioral and emotional aspects. When it is persistent, it can become debilitating, impairing occupational performance, and producing negative impacts for the economy and public health costs. In general, commercial drugs can improve chronic pain patients' quality of life which can result in adverse reactions. Therefore, the search for new capsules as an opportunity remedy for ache is a challenge. Pain occurs due to stimuli from pain receptors called nociceptors. One pain known in the medical world is orofacial, defined as pain that occurs in soft and hard tissue in the head, face, and neck area. This study determined the antinociceptive effect of flavonoids isolated from the Leea Indica plant, on orofacial pain in zebrafish (Danio rerio) as a test model for behavior or locomotor activity. To study the orofacial pain of zebrafish induced with glutamate, this study was a true experiment. The parameter used was the number of times the fish crossed the line between the caudran from the glass petri dish during 0-5 minutes and 15-30 minutes. The Anova one-way test showed that there were differences in locomotors activity measured from 0-5 minutes and 15-30 minutes by giving flavonoids that could affect zebrafish locomotors activity or an increase in zebrafish locomotors activity. The antinociceptive effect of flavonoids was similar to tramadol. The flavonoids from Leea Indica had an antinociceptive effect on orofacial pain in adult zebrafish. The flavonoid dose of 2.5 mg/ml was a dose that had a significant difference in all treatment groups.
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Interventional Therapies for Pain in Cancer Patients: a Narrative Review. Curr Pain Headache Rep 2021; 25:44. [PMID: 33961156 DOI: 10.1007/s11916-021-00963-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Pain is a prevalent symptom in the lives of patients with cancer. In light of the ongoing opioid epidemic and increasing awareness of the potential for opioid abuse and addiction, clinicians are progressively turning to interventional therapies. This article reviews the interventional techniques available to mitigate the debilitating effects that untreated or poorly treated pain have in this population. RECENT FINDINGS A range of interventional therapies and technical approaches are available for the treatment of cancer-related pain. Many of the techniques described may offer effective analgesia with less systemic toxicity and dependency than first- and second-line oral and parenteral agents. Neuromodulatory techniques including dorsal root ganglion stimulation and peripheral nerve stimulation are increasingly finding roles in the management of oncologic pain. The goal of this pragmatic narrative review is to discuss interventional approaches to cancer-related pain and the potential of such therapies to improve the quality of life of cancer patients.
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Deer TR, Abd-Elsayed A, Falowski S, Hagedorn JM, Abejón D, Russo M, Engle A, Hah JM, Lamer TJ, Carayannopoulos AG, Hunter C, Steegers M, Pope J. Practice Choices in Targeted Intrathecal Drug Delivery: An Online Survey Conducted by the Polyanalgesic Consensus Committee. Neuromodulation 2020; 24:1139-1144. [PMID: 33368847 DOI: 10.1111/ner.13335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/18/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Alaa Abd-Elsayed
- University of Wisconsin Pain Clinic, Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | | | - David Abejón
- Jefe de Departamento, Unidad de Dolor Grupo Quirón-Salud, Madrid, Spain
| | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | - Alyson Engle
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Alexios G Carayannopoulos
- Physical Medicine and Rehabilitation, Comprehensive Spine Center, Rhode Island Hospital, Providence, RI, USA.,Lifespan Physician Group, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Monique Steegers
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
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Deer T, Hagedorn JM. How has ziconotide impacted non-cancer pain management? Expert Opin Pharmacother 2020; 21:507-511. [DOI: 10.1080/14656566.2019.1707182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
- President & CEO of the Centre for Pain Relief, Charleston, WV, USA
| | - Jonathan M. Hagedorn
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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Mekhail N, Mehanny DS, Armanyous S, Costandi S, Saweris Y, Azer G, Bolash R. Choice of spinal cord stimulation versus targeted drug delivery in the management of chronic pain: a predictive formula for outcomes. Reg Anesth Pain Med 2020:rapm-2019-100859. [PMID: 31932490 DOI: 10.1136/rapm-2019-100859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 11/21/2019] [Accepted: 11/23/2019] [Indexed: 11/03/2022]
Abstract
Contemporary nonmalignant pain treatment algorithms commence with conservative non-invasive strategies, later progressing from minimally invasive interventions to invasive techniques or implantable devices. The most commonly used implantable devices are spinal cord stimulation (SCS) systems or targeted drug delivery (TDD) devices. Historically, SCS had been considered in advance of TDD, positioning TDD behind SCS failures. Following Institutional Review Board approval, data were extracted from electronic medical records of patients who underwent SCS trial in the Department of Pain Management at Cleveland Clinic from 1994 to 2013. The sample size was analyzed in two cohorts: those who succeeded with SCS and those who failed SCS and consequently proceeded to TDD. Univariate and multivariate analyses were performed and a predictive formula for successful outcomes was created. 945 patients were included in the cohort of which 119 (12.6%) subjects achieved adequate pain relief with TDD after failure of SCS. Gender, age, depression and primary pain diagnosis were significantly different in this subgroup. Males were 52% less likely to experience pain relief with SCS. The odds of SCS success decreased as age increased by 6% per year. Patients with comorbid depression, interestingly, were 63% more likely to succeed with SCS. A logistic model was created to predict SCS success which was used to create a predictive formula. Older male patients diagnosed with spine-related pain were more likely to benefit from TDD than SCS. This observation potentially identifies a subgroup in whom consideration for TDD in advance of SCS failure could prove more efficient and cost effective. These retrospective findings warrant prospective comparative studies to validate this derived predictive formula.
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Affiliation(s)
- Nagy Mekhail
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Diana S Mehanny
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Sherif Armanyous
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Shrif Costandi
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Youssef Saweris
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Gerges Azer
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert Bolash
- Evidence-Based Pain Management Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Graviola Fruit Bar Added Acerola By-Product Extract Protects Against Inflammation and Nociception in Adult Zebrafish ( Danio rerio). J Med Food 2019; 23:173-180. [PMID: 31502908 DOI: 10.1089/jmf.2019.0078] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Studies involving foods associated with pain reversal and anti-inflammatory effects using zebrafish are rarely reported in the literature. This study aimed to evaluate the effect of graviola (Annona muricata L.) fruit bar (GFB) and GFB added with acerola (Malpighia glabra L) seed extract (ASE) on acute nociception and abdominal inflammation in adult zebrafish (Danio rerio). Acute nociception was induced by formalin, capsaicin, cinnamaldehyde, acidic saline, glutamate (cutaneous models), and hypertonic saline (corneal model), and inflammation was induced by carrageenan. Both GFB and ASE exhibited antinociceptive effect modulated by the nitrergic system, guanylate cyclase, and transient receptor potential ankyrin 1 and acid-sensing ion channels. The antinociceptive effect of GFB also appears to be modulated by the opioid system and glutamatergic receptors (N-methyl-D-aspartate receptor). Only ASE presented corneal antinociceptive effect. Both samples showed anti-inflammatory effect, being more significant the effect of GFB. The addition of acerola by-product extract in GFB results in a product with greater biological potential.
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Deer TR, Pope JE, Hanes MC, McDowell GC. Intrathecal Therapy for Chronic Pain: A Review of Morphine and Ziconotide as Firstline Options. PAIN MEDICINE 2019; 20:784-798. [PMID: 30137539 PMCID: PMC6442748 DOI: 10.1093/pm/pny132] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objectives To evaluate the evidence for morphine and ziconotide as firstline intrathecal (IT) analgesia agents for patients with chronic pain. Methods Medline was searched (through July 2017) for “ziconotide” or “morphine” AND “intrathecal” AND “chronic pain,” with results limited to studies in human populations. Results The literature supports the use of morphine (based primarily on noncontrolled, prospective, and retrospective studies) and ziconotide (based on randomized controlled trials and prospective observational studies) as first-choice IT therapies. The 2016 Polyanalgesic Consensus Conference (PACC) guidelines recommended both morphine and ziconotide as firstline IT monotherapy for localized and diffuse chronic pain of cancer-related and non–cancer-related etiologies; however, one consensus point emphasized ziconotide use, unless contraindicated, as firstline IT therapy in patients with chronic non–cancer-related pain. Initial IT therapy choice should take into consideration individual patient characteristics (e.g., pain location, response to previous therapies, comorbid medical conditions, psychiatric history). Trialing is recommended to assess medication efficacy and tolerability. For both morphine and ziconotide, the PACC guidelines recommend conservative initial dosing strategies. Due to its narrow therapeutic window, ziconotide requires careful dose titration. Ziconotide is contraindicated in patients with a history of psychosis. IT morphine administration may be associated with serious side effects (e.g., respiratory depression, catheter tip granuloma), require dose increases, and cause dependence over time. Conclusion Based on the available evidence, morphine and ziconotide are recommended as firstline IT monotherapy for cancer-related and non–cancer-related pain. The choice of first-in-pump therapy should take into consideration patient characteristics and the advantages and disadvantages of each medication.
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Affiliation(s)
- Timothy R Deer
- The Center for Pain Relief, Spine and Nerve Centers of The Virginias, Charleston, West Virginia
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11
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Antinociceptive activity of ethanolic extract of Azadirachta indica A. Juss (Neem, Meliaceae) fruit through opioid, glutamatergic and acid-sensitive ion pathways in adult zebrafish (Danio rerio). Biomed Pharmacother 2018; 108:408-416. [DOI: 10.1016/j.biopha.2018.08.160] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 08/30/2018] [Accepted: 08/31/2018] [Indexed: 11/20/2022] Open
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McDowell GC, Winchell J. Role of primary care physicians in intrathecal pain management: a narrative review of the literature. Postgrad Med 2018. [PMID: 29542370 DOI: 10.1080/00325481.2018.1448207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The majority of patients seeking medical care for chronic pain consult a primary care physician (PCP). Because systemic opioids are commonly prescribed to patients with chronic pain, PCPs are attempting to balance the competing priorities of providing adequate pain relief while reducing risks for opioid misuse and overdose. It is important for PCPs to be aware of pain management strategies other than systemic opioid dose escalation when patients with chronic pain fail to respond to conservative therapies and to initiate a multimodal treatment plan. METHODS The Medline database and evidence-based treatment guidelines were searched to identify publications on intrathecal (IT) therapy for the management of chronic pain. Selection of publications relevant to PCPs was based on the authors' clinical and research expertise. RESULTS IT administration delivers analgesic medication directly into the cerebrospinal fluid, avoiding first-pass effect and bypassing the blood-brain barrier, thereby requiring lower medication doses. Morphine, a µ-opioid receptor agonist, and ziconotide, a non-opioid, selective N-type calcium channel blocker, are the only analgesics approved by the US Food and Drug Administration to treat chronic refractory pain by the IT route. Patients who are potential candidates for IT therapy may benefit from evaluation by an interventional pain physician. PCPs can play an important role in patient selection and referral for IT therapy and provide ongoing collaborative care for patients receiving IT therapy, including monitoring for efficacy and adverse events and facilitating communication with the treating specialist. CONCLUSIONS Collaboration between PCPs and pain specialists may improve outcomes of and patient satisfaction with IT therapy and other interventional treatments.
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Exploring Nonopioid Analgesic Agents for Intrathecal Use. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00068-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Objective Physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs) provide professional services on pain management teams. This review provides an overview of the practical management of chronic pain with intrathecal (IT) therapy using an interprofessional approach (eg, physicians and other health care professionals), with a focus on the contributions of PAs, NPs, and RNs. Methods Narrative review based on literature searches of the Medline database and treatment guidelines on the use of IT therapy in the management of patients with chronic pain. Results The specific roles and responsibilities of PAs, NPs, and RNs in the management of patients receiving IT therapy vary by practice. In many pain treatment centers, PAs, NPs, and RNs are responsible for patient education, postimplant maintenance, and ongoing supportive care of patients receiving IT therapy. Topics that we address include patient selection, patient expectations and goal setting, medication selection, outcome assessment, and treatment adjustment. Currently, morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker) are the only agents approved by the US Food and Drug Administration for IT analgesia. We provide relevant information on the dosing, titration, and adverse effect management of these medications for PAs, NPs, and RNs responsible for administering IT therapy. Conclusion PAs, NPs, and RNs are valuable members of IT pain management teams. Treatment success requires ongoing monitoring of efficacy and adverse effects, with corresponding adjustments to medication selection and dosing, in addition to good communication among the health care professionals involved in patient care.
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Affiliation(s)
| | - Neona M Lotz
- Cypress Ambulatory Surgery Center, Santa Maria, CA, USA
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De Prá SDT, Ferro PR, Milioli AM, Rigo FK, Chipindo OJ, Camponogara C, Casoti R, Manfron MP, de Oliveira SM, Ferreira J, Trevisan G. Antinociceptive activity and mechanism of action of hydroalcoholic extract and dichloromethane fraction of Amphilophium crucigerum seeds in mice. JOURNAL OF ETHNOPHARMACOLOGY 2017; 195:283-297. [PMID: 27864110 DOI: 10.1016/j.jep.2016.11.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 10/16/2016] [Accepted: 11/15/2016] [Indexed: 06/06/2023]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE The medicinal plant generally known as monkey's comb (Amphilophium crucigerum) has been popularly described for the treatment of neuropathic and inflammatory pain, specially seeds preparations. AIM OF THE STUDY The goal of the present study was to evaluate the antinociceptive effect of the crude extract (Crd) and dichloromethane fraction (Dcm) of A. crucigerum seeds, and investigate the involvement of transient receptor potential vanilloid 1 (TRPV1) receptor in this effect. MATERIALS AND METHODS Male Swiss mice were used in this study. The effects of Crd and Dcm was tested on capsaicin-induced Ca2+ influx or the specific binding of [3H]-resiniferatoxin. Moreover, after treatment with Crd or Dcm, animals were exposed to acute pain (hot water tail-flick and capsaicin intraplantar test) or chronic pain models (injection of complete Freund's adjuvant or partial ligation of the sciatic nerve). Acute adverse effects were also noted: locomotor activity, corporal temperature, hepatic or renal damage, gastrointestinal transit alteration, and ulcerogenic activity. RESULTS The oral administration of Crd or Dcm resulted in an antinociceptive effect in the hot water tail-flick (48°C) and capsaicin intraplantar tests. Furthermore, these preparations exhibited antinociceptive and anti-inflammatory effects in a chronic inflammatory pain model, and antinociceptive effects in a neuropathic pain model. Moreover, Crd and Dcm reduced capsaicin-induced Ca2+ influx and diminished the [3H]-resiniferatoxin specific binding to spinal cord membranes. Acute adverse events were not found with Crd or Dcm administration. CONCLUSION In conclusion, our results support the analgesic effect of A. crucigerum and suggest the presence of compounds that may act as TRPV1 antagonists.
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Affiliation(s)
- Samira Dal Toé De Prá
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (Unesc), 88006-000 Criciúma (SC), Brazil.
| | - Paula Ronsani Ferro
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (Unesc), 88006-000 Criciúma (SC), Brazil.
| | - Alessandra Marcon Milioli
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (Unesc), 88006-000 Criciúma (SC), Brazil.
| | - Flávia Karine Rigo
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (Unesc), 88006-000 Criciúma (SC), Brazil.
| | - Orlando Justo Chipindo
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (Unesc), 88006-000 Criciúma (SC), Brazil.
| | - Camila Camponogara
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil.
| | - Rosana Casoti
- Programa de Pós-Graduação em Ciências Farmacêuticas, Universidade de São Paulo (USP - Ribeirão Preto), 14040-903 Ribeirão Preto (SP), Brazil; Programa de Pós-Graduação em Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil.
| | - Melânia Palermo Manfron
- Programa de Pós-Graduação em Ciências Farmacêuticas, Centro de Ciências da Saúde, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil.
| | - Sara Marchesan de Oliveira
- Programa de Pós-Graduação em Ciências Biológicas: Bioquímica Toxicológica, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil.
| | - Juliano Ferreira
- Programa de Pós-Graduação em Farmacologia, Universidade Federal de Santa Catarina (UFSC), 88049-900 Florianópolis (RS), Brazil.
| | - Gabriela Trevisan
- Programa de Pós-Graduação em Ciências da Saúde, Universidade do Extremo Sul Catarinense (Unesc), 88006-000 Criciúma (SC), Brazil; Programa de Pós-Graduação em Farmacologia, Universidade Federal de Santa Maria (UFSM), 97105-900 Santa Maria (RS), Brazil.
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Deer TR, Pope JE, Hayek SM, Bux A, Buchser E, Eldabe S, De Andrés JA, Erdek M, Patin D, Grider JS, Doleys DM, Jacobs MS, Yaksh TL, Poree L, Wallace MS, Prager J, Rauck R, DeLeon O, Diwan S, Falowski SM, Gazelka HM, Kim P, Leong M, Levy RM, McDowell II G, McRoberts P, Naidu R, Narouze S, Perruchoud C, Rosen SM, Rosenberg WS, Saulino M, Staats P, Stearns LJ, Willis D, Krames E, Huntoon M, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines. Neuromodulation 2017; 20:96-132. [DOI: 10.1111/ner.12538] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | - Anjum Bux
- Anesthesia and Chronic Pain Management; Ephraim McDowell Regional Medical Center; Danville KY USA
| | - Eric Buchser
- Anaesthesia and Pain Management Department; EHC Hosptial, Morges, and CHUV University Hospital; Lausanne Switzerland
| | - Sam Eldabe
- The James Cook University Hospital; Middlesbrough UK
| | - Jose A. De Andrés
- Valencia School of Medicine; Hospital General Universitario; Valencia Spain
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- University of Kentucky College of Medicine, UK HealthCare Pain Services; Lexington KY USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology; University of California; San Diego CA USA
| | - Lawrence Poree
- Pain Clinic of Monterey Bay, University of California at San Francisco; San Francisco CA USA
| | | | - Joshua Prager
- Center for the Rehabilitation Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | - Richard Rauck
- Carolina Pain Institute, Wake Forest Baptist Health; Winston-Salem NC USA
| | - Oscar DeLeon
- Roswell Park Cancer Institute, SUNY; Buffalo NY USA
| | - Sudhir Diwan
- Manhattan Spine and Pain Medicine; Lenox Hill Hospital; New York NY USA
| | | | | | - Philip Kim
- Bryn Mawr Hospital; Bryn Mawr PA, USA
- Christiana Hospital; Newark DE USA
| | | | | | | | | | - Ramana Naidu
- San Francisco Medical Center, University of California; San Francisco CA USA
| | - Samir Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | - Peter Staats
- Premier Pain Management Centers; Shrewsbury NJ, USA
- Johns Hopkins University; Baltimore MD USA
| | | | | | - Elliot Krames
- Pacific Pain Treatment Center (ret.); San Francisco CA USA
| | - Marc Huntoon
- Vanderbilt University Medical Center; Nashville TN USA
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Deer TR, Hayek SM, Pope JE, Lamer TJ, Hamza M, Grider JS, Rosen SM, Narouze S, Perruchoud C, Thomson S, Russo M, Grigsby E, Doleys DM, Jacobs MS, Saulino M, Christo P, Kim P, Huntoon EM, Krames E, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Trialing of Intrathecal Drug Delivery Infusion Therapy. Neuromodulation 2017; 20:133-154. [PMID: 28042906 DOI: 10.1111/ner.12543] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Revised: 06/20/2016] [Accepted: 07/06/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Intrathecal (IT) drug infusion is an appropriate and necessary tool in the algorithm to treat refractory cancer and noncancer pain. The decision-making steps/methodology for selecting appropriate patients for implanted targeted drug delivery systems is controversial and complicated. Therefore, a consensus on best practices for determining appropriate use of IT drug infusion may involve testing/trialing this therapy before implantation. METHODS This current Polyanalgesic Consensus Conference (PACC) update was designed to address the deficiencies and emerging innovations since the previous PACC convened in 2012. A literature search identified publications available since the previous PACC publications in 2014, and relevant sources were contributed by the PACC members. After reviewing the literature, the panel determined the evidence levels and degrees of recommendations. The developed consensus was ranked as strong (>80%), moderate (50-79%), or weak (<49%). RESULTS The trialing for IT drug delivery systems (IDDS) remains an area of continued controversy. The PACC recommendations for trialing are presented in 34 consensus points and cover trialing for morphine, ziconotide, and medication admixtures; starting doses and titration practices; measurements of success; trial settings and monitoring; management of systemic opioids during trialing; and the role of psychological evaluation. Finally, the PACC describes clinical scenarios in which IT trialing is required or not required. CONCLUSION The PACC provides consensus guidance on best practices of trialing for IDDS implants. In addition, the PACC recommends that no trial may be required in certain patient populations.
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Affiliation(s)
| | - Salim M Hayek
- Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | | | | | - Maged Hamza
- Virginia Commonwealth University Spine Center, Richmond, VA, USA
| | - Jay S Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Steven M Rosen
- Delaware Valley Pain & Spine Institute, Chalfront, PA, USA
| | | | | | - Simon Thomson
- Basildon and Thurrock University Hospitals FHT, Essex, UK
| | - Marc Russo
- Hunter Pain Clinic, Newcastle, NSW, Australia
| | | | | | | | | | | | - Philip Kim
- Bryn Mawr Hospital, Bryn Mawr, PA, USA.,Christiana Hospital, Newark, DE, USA
| | | | - Elliot Krames
- Pacific Pain Treatment Center (ret.), San Francisco, CA, USA
| | - Nagy Mekhail
- Cleveland Clinic, Evidence-Based Pain Management Research, Cleveland, OH, USA
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18
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Simion V, Nadim WD, Benedetti H, Pichon C, Morisset-Lopez S, Baril P. Pharmacomodulation of microRNA Expression in Neurocognitive Diseases: Obstacles and Future Opportunities. Curr Neuropharmacol 2017; 15:276-290. [PMID: 27397479 PMCID: PMC5412696 DOI: 10.2174/1570159x14666160630210422] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/31/2016] [Accepted: 06/28/2016] [Indexed: 12/21/2022] Open
Abstract
Given the importance of microRNAs (miRNAs) in modulating brain functions and their implications in neurocognitive disorders there are currently significant efforts devoted in the field of miRNA-based therapeutics to correct and/or to treat these brain diseases. The observation that miRNA 29a/b-1 cluster, miRNA 10b and miRNA 7, for instance, are frequently deregulated in the brains of patients with neurocognitive diseases and in animal models of Alzheimer, Huntington's and Parkinson's diseases, suggest that correction of miRNA expression using agonist or antagonist miRNA oligonucleotides might be a promising approach to correct or even to cure such diseases. The encouraging results from recent clinical trials allow envisioning that pharmacological approaches based on miRNAs might, in a near future, reach the requirements for successful therapeutic outcomes and will improve the healthcare of patients with brain injuries or disorders. This review will focus on the current strategies used to modulate pharmacological function of miRNA using chemically modified oligonucleotides. We will then review the recent literature on strategies to improve nucleic acid delivery across the blood-brain barrier which remains a severe obstacle to the widespread application of miRNA therapeutics to treat brain diseases. Finally, we provide a state-of-art of current preclinical research performed in animal models for the treatment of neurocognitive disorders using miRNA as therapeutic agents and discuss future developments of miRNA therapeutics.
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Affiliation(s)
- Viorel Simion
- Centre de Biophysique Moléculaire, CNRS UPR4301, Université d’Orléans France, 45071 Orléans Cedex, France
| | - Wissem Deraredj Nadim
- Centre de Biophysique Moléculaire, CNRS UPR4301, Université d’Orléans France, 45071 Orléans Cedex, France
| | - Hélène Benedetti
- Centre de Biophysique Moléculaire, CNRS UPR4301, Université d’Orléans France, 45071 Orléans Cedex, France
| | - Chantal Pichon
- Centre de Biophysique Moléculaire, CNRS UPR4301, Université d’Orléans France, 45071 Orléans Cedex, France
| | - Severine Morisset-Lopez
- Centre de Biophysique Moléculaire, CNRS UPR4301, Université d’Orléans France, 45071 Orléans Cedex, France
| | - Patrick Baril
- Centre de Biophysique Moléculaire, CNRS UPR4301, Université d’Orléans France, 45071 Orléans Cedex, France
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19
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Prusik J, Argoff C, Peng S, Pilitsis JG. Use of Low Dose Ziconotide as First-Line Intrathecal Monotherapy. Neuromodulation 2016; 20:386-391. [DOI: 10.1111/ner.12486] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/12/2016] [Accepted: 07/12/2016] [Indexed: 02/01/2023]
Affiliation(s)
- Julia Prusik
- Department of Neurosurgery; Albany Medical Center; Albany NY USA
- Department of Neurology; Albany Medical Center; Albany NY USA
- Department of Neuroscience and Experimental Therapeutics; Albany Medical College; Albany NY USA
| | - Charles Argoff
- Department of Neurology; Albany Medical Center; Albany NY USA
| | - Sophia Peng
- Department of Neurosurgery; Albany Medical Center; Albany NY USA
| | - Julie G. Pilitsis
- Department of Neurosurgery; Albany Medical Center; Albany NY USA
- Department of Neuroscience and Experimental Therapeutics; Albany Medical College; Albany NY USA
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20
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Abstract
Objective. The increasing incidence of cancer survivorship has shifted treatment of cancer-related pain from short-term analgesia to long-term chronic pain management. As a result, alternatives to oral analgesics, such as intrathecal therapy, may be beneficial for patients with cancer-related pain. The authors review the use of intrathecal therapy in the management of cancer-related pain. Methods. The Medline database was searched for English-language articles that included “ziconotide” or “morphine” AND (“cancer” OR “malignant”) AND “intrathecal” in title or abstract. Available abstracts from scientific congresses in the areas of neuromodulation and oncology were also reviewed. Results. Intrathecal therapy provides pain relief with reduced systemic concerns in patients with cancer-related pain. Patients should undergo multidisciplinary evaluation and, in most cases, drug trialing before intrathecal pump implantation. Morphine, an opioid (µ-opioid receptor antagonist), and ziconotide, a nonopioid (selective N-type calcium channel inhibitor), are both approved for intrathecal analgesia; however, tolerance and safety concerns may deter the use of intrathecal morphine. Ziconotide has also shown efficacy for reduction of cancer-related pain; however, proper dosing and titration must be used to prevent adverse events. There is little information available on use of intrathecal therapies specifically in cancer survivors. Conclusions. Treatment of cancer-related pain has shifted toward chronic pain management strategies, especially among cancer survivors. Intrathecal therapy provides an alternate route of administration of chronic pain medications (e.g., morphine and ziconotide) for cancer patients with and without active disease, although additional research is needed to support effectiveness in cancer survivors.
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Affiliation(s)
- Brian M Bruel
- *University of Texas, MD Anderson Cancer Center, Houston, Texas
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21
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Gupta R, Shodhan S, Hosny A. Retrograde Epidural Catheter Relieves Intractable Sacral Pain. Indian J Palliat Care 2016; 22:180-2. [PMID: 27162431 PMCID: PMC4843559 DOI: 10.4103/0973-1075.179604] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pain caused by tumor infiltration of the sacral area remains a major clinical challenge. Patients with poor pain control despite comprehensive medical management may be treated with neuraxial techniques such as continuous epidural or spinal anesthetic. We report a case in which a patient with metastatic breast cancer experienced inadequate pain relief after multiple intravenous pain management regimens as well as intrathecal (IT) drug delivery. The concentration of local anesthetics delivered via the IT catheter was limited due to the patient's baseline motor weakness which would be exacerbated with higher concentrations of local anesthetics. Thus, a decision was made to insert an epidural catheter via a retrograde technique to provide the patient with a "band of anesthesia" which would provide profound sensory blockade without concomitant motor weakness. Pain refractory to other modalities of pain control was successfully treated with the epidural technique.
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Affiliation(s)
- Ruchir Gupta
- Department of Anesthesiology, School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Shivam Shodhan
- St. George's University School of Medicine, St. George's Medical College, Grenada
| | - Amr Hosny
- Department of Anesthesiology, New York Medical College, NY, USA
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22
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Pope JE, Deer TR, Bruel BM, Falowski S. Clinical Uses of Intrathecal Therapy and Its Placement in the Pain Care Algorithm. Pain Pract 2016; 16:1092-1106. [PMID: 26914961 DOI: 10.1111/papr.12438] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/17/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
Intrathecal drug delivery is an effective treatment option for patients with severe chronic pain who have not obtained adequate analgesia from more conservative therapies (eg, physical therapy, systemic opioids, nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsants). This review focuses on, but is not limited to, the 2 agents currently approved by the U.S. Food and Drug Administration for intrathecal analgesia: preservative-free morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker). We describe the appropriate use of intrathecal therapy in the management of severe chronic pain, based on current best practices. Topics addressed here include patient selection, trialing, dosing and titration, adverse event profiles, long-term management, intrathecal therapy for cancer-related pain, and the placement of intrathecal therapy in the pain care algorithm. In appropriately selected patients with chronic pain, intrathecal therapy can provide substantial pain relief with improved functioning and quality of life. Successful long-term management requires ongoing patient monitoring for changes in efficacy and the occurrence of adverse events, with subsequent changes in intrathecal dosing and titration, the addition of adjuvant intrathecal agents, and the use of concomitant oral medications to address side effects, as needed. Based on an infrequent but clinically concerning risk of overdose, granuloma, and other opioid-induced complications, nonopioid therapy with ziconotide may be preferred as a first-line intrathecal therapy in patients without a history of psychosis or allergy.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, Santa Rosa, California, U.S.A
| | - Timothy R Deer
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Brian M Bruel
- University of Texas, M.D. Anderson Cancer Center, Houston, Texas, U.S.A
| | - Steven Falowski
- St. Luke's Neurosurgical Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, U.S.A
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McDowell GC, Pope JE. Intrathecal Ziconotide: Dosing and Administration Strategies in Patients With Refractory Chronic Pain. Neuromodulation 2016; 19:522-32. [PMID: 26856969 PMCID: PMC5067570 DOI: 10.1111/ner.12392] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 11/10/2015] [Indexed: 11/30/2022]
Abstract
Introduction Ziconotide is a non‐opioid analgesic for intrathecal (IT) administration. The aim of this review is to provide a comprehensive and clinically relevant summary of the literature on dosing and administration with IT ziconotide in the management of refractory chronic pain, and to describe novel dosing strategies intended to improve clinical outcomes. Materials and Methods A Medline search was conducted for “ziconotide,” supplemented by manual searching of published bibliographies and abstracts from conferences. Results Early experience with IT ziconotide in clinical trials combined with improved understanding of drug pharmacokinetics in the cerebrospinal fluid have led to a reappraisal of approaches to trialing and initiation of continuous‐infusion therapy in an effort to improve tolerability. The traditional paradigm of trialing by inpatient continuous infusion may be shifting toward outpatient trialing by IT bolus, although definitions of success and specific protocols remain to be agreed upon. Expert consensus on IT continuous infusion with ziconotide suggests a starting dose of 0.5 to 1.2 mcg/day followed by dose titration of ≤0.5 mcg/day on a no more than weekly basis, according to individual patients’ pain reductions and regimen tolerability. Discussion Newer modalities that include patient‐controlled analgesia and nocturnal flex dosing have been shown to hold promise of further improvements in ziconotide efficacy and tolerability. Conclusions Clinical trials and experience confirm the feasibility and usefulness of IT ziconotide in the management of refractory chronic pain. Emerging evidence suggests that additional IT delivery options may further expand the usefulness and benefits of ziconotide.
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de la Calle Gil AB, Peña Vergara I, Cormane Bornacelly MA, Pajuelo Gallego A. Intrathecal Ziconotide and Morphine for Pain Relief: A Case Series of Eight Patients with Refractory Cancer Pain, Including Five Cases of Neuropathic Pain. Neurol Ther 2015; 4:159-68. [PMID: 26563119 PMCID: PMC4685866 DOI: 10.1007/s40120-015-0035-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction Studies have shown that, at low doses and with careful titration, combination therapy with intrathecal ziconotide and morphine results in rapid control of opioid-refractory cancer pain. However, there is a lack of published data regarding the efficacy and safety of intrathecal ziconotide specifically for the treatment of neuropathic cancer pain. Case series Case reports of ziconotide intrathecal infusion in eight patients (age 45–71 years; 75% male) with chronic, uncontrolled cancer pain during therapy with intrathecal morphine plus bupivacaine were reviewed. Neuropathic pain was confirmed in five patients. Treatment was initiated with adjunctive ziconotide when pain ≥5 on a visual analog scale persisted in spite of 3 successive 20% dose increases of intrathecal morphine. Ziconotide was initiated at 0.5–1.0 µg/day, with mean increases of 0.5 µg every 4–7 days if required (maximum dose 10 µg/day; mean dose 4.9 µg/day). Pain intensity was reduced in all patients after 3–5 days. Of the eight patients, three died for reasons unrelated to ziconotide, three discontinued treatment due to adverse effects (predominantly psychoneurological disorders), and one patient is still receiving treatment. One patient discontinued ziconotide due to confusion and delirium. Due to continued lack of pain control with intrathecal morphine, intrathecal fentanyl was initiated; however, effective pain relief was not achieved with 1500 µg/day. Ziconotide was restarted and the patient then achieved pain control. Conclusion On the basis of our clinical experience, we recommend adding ziconotide to intrathecal opioid-based therapy in cancer patients with neuropathic pain inadequately controlled by intrathecal morphine alone. Funding Eisai, Spain. Electronic supplementary material The online version of this article (doi:10.1007/s40120-015-0035-z) contains supplementary material, which is available to authorized users.
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