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Hao D, Di Capua CA, Dumas C, Rosenblum S, Thorne R, Narang S. Real-World Prescription Data for Intrathecal Drug Delivery: A Retrospective Analysis in 32,784 Patients. Neuromodulation 2024:S1094-7159(24)00661-5. [PMID: 39230529 DOI: 10.1016/j.neurom.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 07/16/2024] [Accepted: 07/17/2024] [Indexed: 09/05/2024]
Abstract
OBJECTIVES Currently, there are three monotherapy drugs approved by the United States Food and Drug Administration (FDA) for use in intrathecal drug delivery systems (IDDS): morphine, ziconotide, and baclofen. In practice, use includes alternate drugs, drug combinations, and drug concentrations. There is a paucity of real-world data examining prescription patterns for IDDS. Our analysis explores a one-year sample of prescription intrathecal (IT) medications from a large pharmaceutical data base to characterize medication usage in IDDS. MATERIALS AND METHODS Data were provided by an accredited pharmacy as a deidentified data base of IT drug prescriptions. Statistical analyses included rates of monotherapy vs combination therapies, frequencies of various IT prescriptions, use of on- vs off-label medications, and opioid vs nonopioid formulations. RESULTS Data were extracted from February 1, 2021 to February 14, 2022. No patients were excluded. The initial sample comprised 49,917 individual IT prescriptions for 32,784 patients. Monotherapies constituted 55.0% of all prescriptions (27,475/49,917). Of these, 23,257 prescriptions (84.6%) were opioid based, with the most common medications being morphine (46.5%), hydromorphone (39.4%), and fentanyl (13.5%). Although 29.3% of all prescriptions were for one of the FDA-approved medications, only 7.9% used FDA-approved concentrations; 9865 patients underwent ≥one prescription change in the study period-16.7% of whom were initially prescribed medications that met the approved, on-label indications for the pump before being switched to off-label concentrations or combinations to address clinical needs. CONCLUSIONS Despite the prevalence of IDDS for managing chronic, intractable pain, minimal data exist on real-world prescription practices. Our study found that FDA-approved IT formulations accounted for the minority of prescriptions, indicating significant practice variation, with off-label prescriptions being common.
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Affiliation(s)
- David Hao
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | - Christopher A Di Capua
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Cindy Dumas
- Advanced Infusion Solutions Healthcare, Dallas, TX, USA
| | | | - Rachel Thorne
- Advanced Infusion Solutions Healthcare, Dallas, TX, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Beth Israel Lahey Health, Boston, MA, USA
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Mahmoud A, Aman MM, Trumbo JL, Paracha U, Langell A, Petersen E. Education and Experience in Intrathecal Drug Delivery Systems (IDDS) During Pain Medicine Fellowships. J Pain Res 2023; 16:4367-4377. [PMID: 38162405 PMCID: PMC10757777 DOI: 10.2147/jpr.s428851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 11/18/2023] [Indexed: 01/03/2024] Open
Abstract
Objective Targeted drug delivery (TDD) via intrathecal drug delivery systems (IDDS) exposure and clinical adoption remains low despite multiple well-designed trials that demonstrate safety, efficacy, reliability, and cost-saving benefits. This study aims to understand the possible contributing factors starting with Pain Medicine fellowship training. Materials and Methods An internet-based, anonymous pilot survey was distributed to pain medicine fellows enrolled in an Accreditation Council for Graduate Medical Education (ACGME) accredited pain medicine training program during the 2021-2022 academic year. Fellowship programs were identified using published online ACGME accreditation data. The survey was distributed via email to fellowship program directors and coordinators and was made available through pain medicine societies. Results Seventy-one of four hundred and twenty-three pain medicine fellows (17% response rate) completed the survey. Nine percent of respondents evidence-informed opinion coincided with the most recent Polyanalgesic Consensus Conference (PACC) guidelines recommendations for IDDS treatment indications. Fifty-one percent of respondents felt there was an unmet need for IDDS training. About one-third of respondents felt that lack of curriculum, faculty, and cases were barriers to IDDS use, respectively. Thirty-one percent of fellows reported sufficient training for IDDS in their fellowship programs. The majority (70%) of respondents somewhat or strongly support direct training by IDDS manufacturers. Conclusion A wide variability exists surrounding IDDS training during ACGME accredited pain medicine fellowship. Insufficient case exposure and lack of a standardized curriculum may play a role in future therapy adoption. The results from this study call for a more standardized training approach with an emphasis on adequate clinical exposure, utilization of peer reviewed educational curriculum and supplemental material to aid pain medicine fellows' education.
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Affiliation(s)
- Ammar Mahmoud
- Department of Pain Medicine, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Mansoor M Aman
- Department of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Jennifer L Trumbo
- Clinical Research Center, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Umera Paracha
- Department of Neurology, Northern Light Eastern Maine Medical Center, Bangor, ME, USA
| | - Ashley Langell
- Department of Pain Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Van Zundert J, Rauck R. Intrathecal drug delivery in the management of chronic pain. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Wang H, Tan JYB, Wang T, Liu XL, Bressington D, Zheng SL, Huang HQ. Feasibility and potential effects of breathing exercise for chronic pain management in breast cancer survivors: study protocol of a phase II randomised controlled trial. BMJ Open 2022; 12:e064358. [PMID: 36517097 PMCID: PMC9756203 DOI: 10.1136/bmjopen-2022-064358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 10/11/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Chronic pain is a common symptom significantly affecting the quality of life of breast cancer survivors. Despite the achievement of pharmacological interventions, the barriers associated with this approach such as inaccessibility, misuse and side effects drive research into effective non-pharmacological interventions to improve chronic pain management, quality of life, anxiety and depression. Breathing exercise (BE) can be a promising option, but research evidence is sparse. This pilot study aims to examine the feasibility and preliminary effect of using an evidence-based BE intervention for chronic pain management in breast cancer survivors. METHOD AND ANALYSIS This study will be a two-parallel-arm, open-labelled, phase II randomised controlled trial with 1:1 allocation. Seventy-two participants will be recruited from a tertiary hospital in China and randomly allocated to either a BE intervention group (n=36) or a control group (n=36). The participants in the intervention group will receive the usual care, a pain information booklet and a 4-week self-administered BE intervention; the participants in the control group will receive the usual care and the pain information booklet only. The assessment will be conducted at three time points: baseline (week 0), immediately after the intervention completion (week 5) and 4 weeks after the intervention completion (week 9). The primary outcomes will be the acceptability and feasibility assessment of the study protocol and methodological procedures. The secondary outcomes will be the effects of BE on pain, quality of life, anxiety and depression in breast cancer survivors. Descriptive statistics will be applied to present the primary outcomes and the Generalised Estimating Equation Model will be utilised to analyse the clinical outcomes. ETHICS AND DISSEMINATION This study has received ethical approvals from the Human Research Ethics Committee at Charles Darwin University (H21089) and the Clinical Trial Ethics Committee at the Affiliated Hospital of Southwest Medical University (KY2022107). Findings from this study will be presented at academic conferences and submitted to peer-reviewed journals for publication. TRIAL REGISTRATION NUMBER ClinicalTrials.gov: NCT05257876.
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Affiliation(s)
- Haiying Wang
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | - Jing-Yu Benjamin Tan
- Faculty of Health, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Tao Wang
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | - Xian-Liang Liu
- Faculty of Health, Charles Darwin University, Brisbane, Queensland, Australia
| | - Daniel Bressington
- Faculty of Health, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Si-Lin Zheng
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
| | - Hou-Qiang Huang
- The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan, China
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Schultz DM, Abd‐Elsayed A, Calodney A, Stromberg K, Weaver T, Spencer RJ. Targeted Drug Delivery for Chronic Nonmalignant Pain: Longitudinal Data From the Product Surveillance Registry. Neuromodulation 2021; 24:1167-1175. [PMID: 33449428 PMCID: PMC8597001 DOI: 10.1111/ner.13353] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/12/2020] [Accepted: 12/07/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To assist in assessment of therapy risks and benefits of targeted drug delivery (TDD) for chronic nonmalignant pain using registry data on product performance, adverse events, and elective device replacement. MATERIALS AND METHODS The Product Surveillance Registry (PSR) (NCT01524276) is an ongoing prospective, long-term, multicenter registry enrolling consented patients implanted with an intrathecal drug delivery system. Patients are followed prospectively with participating investigators providing pump and catheter performance data for events related to the device, procedure, and therapy. Event descriptions include patient symptoms and outcomes. RESULTS Registry data from the 4646 patients (59.7% female) treated with TDD for chronic, nonmalignant pain at 59 registry sites between August 2003 and October 2019, with over 17,000 patient-years (4646 patients with 44 months average follow-up), were analyzed. Registry discontinuation was largely (46.2% of discontinued patients) due to study site closure and patient death; exit due to an adverse or device event was limited to 10.2%. CONCLUSIONS Treating chronic pain with escalating doses of strong systemic opioids often leads to inconsistent pain control, impaired function, untenable side effects, and reduced quality of life and this practice has contributed to the current opioid crisis in the United States. TDD has been an available therapy for these patients for greater than 30 years, and data from this real-world registry offer supporting evidence to the long-term safety of this therapy as an alternative to systemic opioids, as well as insights into patient acceptance and satisfaction.
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Affiliation(s)
| | - Alaa Abd‐Elsayed
- Department of AnesthesiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWIUSA
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Fons K, Jnah AJ. Arnold-Chiari Malformation: Core Concepts. Neonatal Netw 2021; 40:313-320. [PMID: 34518383 DOI: 10.1891/11-t-704] [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] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
Arnold-Chiari malformation (ACM), a defect that involves downward displacement of the hindbrain and herniation of the cerebellar vermis, tonsils, pons, medulla, and fourth ventricle through the foramen magnum, is the most complex of the 4 types of Chiari malformations. Unique to the other types of Chiari malformations, approximately 95 percent of infants with ACM also present with an associated myelomeningocele (MMC), the most severe form of spina bifida. Among affected infants, those with symptomatic comorbidities incur a significantly higher morbidity and mortality risk. Prompt identification and diagnosis of ACM, as well as evidence-based postnatal and postsurgical nursing and medical care, is critical. Early surgical intervention can repair an existing MMC and restore proper cerebrospinal fluid circulation, which can dramatically improve patient outcomes and quality of life, and reduce disease and health care burden.
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Flotats-Bastardas M, Hahn A, Schwartz O, Linsler S, Meyer S, Kolodziej M, Koehler C. Multicenter Experience with Nusinersen Application via an Intrathecal Port and Catheter System in Spinal Muscular Atrophy. Neuropediatrics 2020; 51:401-406. [PMID: 33091940 DOI: 10.1055/s-0040-1715481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Nusinersen, an antisense oligonucleotide enhancing the production of the survival motor neuron protein, is approved for the treatment of spinal muscular atrophy (SMA) but requires repetitive lumbar punctures. Application via a subcutaneous port connected to a permanent intrathecal catheter has been proposed as an alternative for patients with severe scoliosis, spinal fusion, or comorbidities, rendering serial interlaminar punctures complicated and risky. Since experience with this technique is sparse and follow-up data are lacking, we assessed feasibility, safety, and tolerability of this approach in eight patients with SMA II/SMA III receiving Nusinersen in a multicenter study. Median age at port implantation was 21 years (range: 10-30 years), and median follow-up time thereafter was 19 months (range: 7-24 months). Leakage of the port catheter occurred in two patients, promptly resolving after resuturing. No further complications such as infection, dislocation, kinking, or obstruction of the port were noted in any of the patients. These findings suggest that application via an intrathecal port and catheter system represents a safe and feasible option for Nusinersen treatment in subjects with SMA. However, to detect rare adverse events longer term follow-up in a larger study cohort is warranted.
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Affiliation(s)
| | - Andreas Hahn
- Department of Child Neurology, University Hospital Giessen, Giessen, Germany
| | - Oliver Schwartz
- Department of Neuropediatrics, Münster University Hospital, Münster, Germany
| | - Steffan Linsler
- Department of Neurosurgery, University Children's Hospital of Saarland, Homburg, Germany
| | - Sascha Meyer
- Department of Neuropediatrics, University Children's Hospital of Saarland, Homburg, Germany
| | | | - Cornelia Koehler
- Department of Neuropediatrics, University Hospitals of the Ruhr University of Bochum, Bochum, Germany
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Fallor MA, Yehl JL, Stewart JT. Successful Administration of Electroconvulsive Therapy in a Patient With an Intrathecal Infusion Pump. PSYCHOSOMATICS 2019; 60:640-642. [PMID: 31337512 DOI: 10.1016/j.psym.2019.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/10/2019] [Accepted: 06/10/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Morgan A Fallor
- Department of Psychiatry, University of South Florida College of Medicine, Tampa, FL
| | - Jennifer L Yehl
- Department of Psychiatry, James A Haley VA Hospital and University of South Florida College of Medicine, Tampa, FL
| | - Jonathan T Stewart
- Department of Psychiatry, James A Haley VA Hospital and University of South Florida College of Medicine, Tampa, FL.
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Usefulness of ultrasound. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2018. [DOI: 10.1097/cj9.0000000000000012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Cui JZ, Zhang XB, Zhu P, Zhao ZB, Geng ZS, Zhang YH, Tian L, Luan HF, Feng JY. Effect of Repetitive Intracutaneous Injections with Local Anesthetics and Steroids for Acute Thoracic Herpes Zoster and Incidence of Postherpetic Neuralgia. PAIN MEDICINE 2017; 18:1566-1572. [PMID: 27492741 DOI: 10.1093/pm/pnw190] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background Treatment of established postherpetic neuralgia (PHN) is difficult and often disappointing. In this study, we assessed the efficacy of repetitive intracutaneous injections with local anesthetics and steroids in acute thoracic herpes zoster (HZ) pain, herpetic eruption, and incidence of PHN. Methods Ninety-three patients with acute thoracic HZ were randomly assigned to receive a standard treatment of antiviral medication with p.o. analgesics or the standard treatment with the addition of repetitive intracutaneous injections of a local anesthetic and steroid mixture. Patients were permitted to take tramadol when the visual analog scale (VAS) ≥ 4. Pain assessment using VAS was conducted at the initial visit, as well as 1, 2, 4, 12, and 24 weeks after the end of the treatments. Results In comparison with the standard treatment group, the VAS scores of the intracutaneous injection group were significantly lower during the study. The intracutaneous injection group also reported shorter duration of pain and skin eruption than the control group ( P = 0.005 vs P < 0.001, respectively). At 1 month post-therapy, 12.8% patients in the intracutaneous injection group reported zoster-associated pain, compared with 47.8% in the standard treatment group ( P < 0.001). At 3 and 6 months post-therapy, the incidence of PHN was still significantly lower in the intracutaneous injection group than the standard treatment group. EuroQol VAS scores were significantly higher in the intracutaneous injection group vs standard treatment group (P < 0.001). Conclusion Repetitive intracutaneous injections with local anesthetics and steroids along with standard treatment significantly reduce the duration of pain and herpetic eruption and incidence of PHN.
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Affiliation(s)
- Ji-Zheng Cui
- Department of Pain Treatment, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Xiao-Bao Zhang
- Department of Anesthesiology, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Pin Zhu
- Department of Anesthesiology, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Zhi-Bin Zhao
- Department of Anesthesiology, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Zhu-Sheng Geng
- Department of Pain Treatment, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Yun-Hai Zhang
- Department of Pain Treatment, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Liang Tian
- Department of Anesthesiology, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Heng-Fei Luan
- Department of Anesthesiology, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
| | - Ji-Ying Feng
- Department of Anesthesiology, the First People's Hospital of Lianyungang City, Lianyungang, Jiangsu Province, People's Republic of China
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