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Chalil A, Staudt MD, Harland TA, Leimer EM, Bhullar R, Argoff CE. A safety review of approved intrathecal analgesics for chronic pain management. Expert Opin Drug Saf 2021; 20:439-451. [PMID: 33583318 DOI: 10.1080/14740338.2021.1889513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Intrathecal (IT) drug therapy is an effective treatment option for patients with chronic pain of malignant or nonmalignant origin, with an established safety profile and fewer adverse effects compared to oral or parenteral pain medications. Morphine (a μ-opioid receptor agonist) and ziconotide (a non-opioid calcium channel antagonist) are the only IT agents approved by the U.S. Food and Drug Administration for the treatment of chronic pain. Although both are considered first-line IT therapies, each drug has unique properties and considerations.Areas Covered: This review will evaluate the pivotal trials that established the use of morphine and ziconotide as first-line IT therapy for patients with chronic pain, as well as safety and efficacy data generated from various retrospective and prospective studies.Expert Opinion: Morphine and ziconotide are effective IT therapies for patients with chronic malignant or nonmalignant pain that is refractory to other interventions. IT ziconotide is recommended as a first-line therapy due to its efficacy and avoidance of many adverse effects commonly associated with opioids. The use of IT morphine is also considered first-line; however, the risks of respiratory depression, withdrawal with drug discontinuation or pump malfunction, and the development of tolerance require careful patient selection and management.
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Affiliation(s)
- Alan Chalil
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael D Staudt
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA.,Michigan Head and Spine Institute, Southfield, Michigan, USA
| | - Tessa A Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Elizabeth M Leimer
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ravneet Bhullar
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York
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2
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[What became of Prialt®? : Observational study on the use of ziconotide in the treatment of chronic pain]. Schmerz 2021; 35:343-348. [PMID: 33507370 PMCID: PMC8452570 DOI: 10.1007/s00482-021-00531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/04/2022]
Abstract
Hintergrund Prialt® ist seit Februar 2005 von der europäischen Arzneimittelbehörde zugelassen und ist neben Morphin das einzige Analgetikum, welches über die offizielle Marktzulassung in der intrathekalen Schmerztherapie verfügt. Da es nicht über Opioidrezeptoren wirkt, galt es zum Zeitpunkt der Markteinführung als nebenwirkungs- und risikoärmer in der Behandlung chronischer Schmerzen als Morphin. Trotzdem gilt es noch heute als Orphan Drug und Studien über den Langzeiteinsatz und hierunter aufgetretene Nebenwirkungen sind rar. Fragestellung Welchen Stellenwert nimmt Prialt® verglichen mit anderen intrathekal verabreichten Analgetika ein? Wie wirken sich die Startdosis und die Geschwindigkeit der Aufdosierung auf die schmerzlindernde Wirkung und das Auftreten von Nebenwirkungen in der Langzeittherapie aus? Material und Methoden Zum einen wurden anhand von Arztbriefen retrospektiv alle Patienten erfasst, die zwischen Februar 2005 und dem Ende des Beobachtungszeitraums im Oktober 2018 Ziconotid in Monotherapie in der Neurochirurgie des Universitätsklinikums Jena erhielten. Zum anderen wurden diese Patienten anhand eines erstellten Fragebogens hinsichtlich ihrer Erfahrung mit Ziconotid befragt. Ergebnisse Bei allen zwölf in die Studie eingeschlossenen Teilnehmern kam es zu mindestens einer Arzneimittelnebenwirkung. Am häufigsten wurde über Vergesslichkeit und Sensibilitätsstörungen mit jeweils 25 % berichtet. Ein Drittel der Patienten musste die Behandlung aufgrund von Nebenwirkungen beenden. Die mittlere Initialdosis betrug 1,98 µg/Tag. Diskussion Trotz leitliniengerechter Behandlung hat sich Ziconotid am Universitätsklinikum Jena nicht gegen Morphin und andere Opioidanalgetika in der intrathekalen Schmerztherapie durchgesetzt. Die Gründe hierfür sind vielfältig, wobei die enge therapeutische Breite, das häufige Auftreten von Nebenwirkungen und die schwierige therapeutische Handhabung, vor allem im ambulanten Setting, von besonderer Bedeutung sind.
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3
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Staub BP, Casini GP, Monaco EA, Sekula RF, Emerick TD. Near-resolution of persistent idiopathic facial pain with low-dose lumbar intrathecal ziconotide: a case report. J Pain Res 2019; 12:945-949. [PMID: 30881103 PMCID: PMC6413753 DOI: 10.2147/jpr.s193746] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Purpose Persistent idiopathic facial pain (PIFP) is a poorly defined and debilitating chronic pain state with a challenging and often inadequate treatment course. This is the first case report identifying the novel use of low-dose lumbar intrathecal ziconotide to successfully treat PIFP with nearly complete resolution of pain and minimal to no side effects. Methods The patient was a 37 year-old female whose PIFP was refractory to multimodal medication management and multiple neurovascular surgical interventions. A single-shot lumbar intrathecal trial of ziconotide (2.5 mL, equivalent 2.5 μg) was injected when she was at her baseline pain level — VAS 7/10. She received complete resolution of her pain for about 9 hours, concordant with ziconotide’s half-life. She was subsequently implanted with a lumbar intrathecal delivery system. Results The patient experienced complete resolution of her facial pain with a single-shot intrathecal trial of ziconotide. The intrathecal pump system has provided nearly complete (VAS 1/10) pain relief. Two flares of pain occurred 10 and 18 months after pump placement, which subsequently resolved after increasing the ziconotide dose by 0.5 μg/day on each occasion. The patient is currently maintained on a dose of 2.0 μg/day and is pain-free. Conclusion This is the first case report describing the use of a single-shot lumbar intrathecal trial of ziconotide and subsequent placement of lumbar (as opposed to thoracic) intrathecal ziconotide pump for PIFP. A single-injection intrathecal trial is a low-risk, viable option for patients with this debilitating and frustrating pain condition. Successful trials and subsequent intrathecal pump placement with ziconotide may supplant multimodal medication management and/or invasive orofacial surgical intervention for PIFP.
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Affiliation(s)
- Brandon P Staub
- Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Edward A Monaco
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Physicians, Pittsburgh, PA, USA,
| | - Raymond F Sekula
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,University of Pittsburgh Physicians, Pittsburgh, PA, USA,
| | - Trent D Emerick
- University of Pittsburgh Physicians, Pittsburgh, PA, USA, .,Division of Chronic Pain, Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA,
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4
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Bäckryd E. Do the potential benefits outweigh the risks? An update on the use of ziconotide in clinical practice. Eur J Pain 2018; 22:1193-1202. [DOI: 10.1002/ejp.1229] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/17/2023]
Affiliation(s)
- E. Bäckryd
- Pain and Rehabilitation Centre; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
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5
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A novel μ-conotoxin from worm-hunting Conus tessulatus that selectively inhibit rat TTX-resistant sodium currents. Toxicon 2017; 130:11-18. [DOI: 10.1016/j.toxicon.2017.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 02/01/2017] [Accepted: 02/16/2017] [Indexed: 12/13/2022]
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Abstract
PURPOSE OF REVIEW To provide an overview on drug targets and emerging pharmacological treatment options for chronic pain. RECENT FINDINGS Chronic pain poses an enormous socioeconomic burden for the more than 30% of people who suffer from it, costing over $600 billion per year in the USA. In recent years, there has been a surge in preclinical and clinical research endeavors to try to stem this epidemic. Preclinical studies have identified a wide array of potential targets, with some of the most promising translational research being performed on novel opioid receptors, cannabinoid receptors, selective ion channel blockers, cytokine inhibitors, nerve growth factor inhibitors, N-methyl-D-aspartate receptor antagonists, glial cell inhibitors, and bisphosphonates. SUMMARY There are many obstacles for the development of effective medications to treat chronic pain, including the inherent challenges in identifying pathophysiological mechanisms, the overlap and multiplicity of pain pathways, and off-target adverse effects stemming from the ubiquity of drug target receptor sites and the lack of highly selective receptor ligands. Despite these barriers, the number and diversity of potential therapies have continued to grow, to include disease-modifying and individualized drug treatments.
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Muller PY, Dambach D, Gemzik B, Hartmann A, Ratcliffe S, Trendelenburg C, Urban L. Integrated risk assessment of suicidal ideation and behavior in drug development. Drug Discov Today 2015; 20:1135-42. [DOI: 10.1016/j.drudis.2015.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 03/10/2015] [Accepted: 05/19/2015] [Indexed: 12/27/2022]
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Bäckryd E, Sörensen J, Gerdle B. Ziconotide Trialing by Intrathecal Bolus Injections: An Open-Label Non-Randomized Clinical Trial in Postoperative/Posttraumatic Neuropathic Pain Patients Refractory to Conventional Treatment. Neuromodulation 2015; 18:404-13. [PMID: 25879804 DOI: 10.1111/ner.12293] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 02/19/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aim of this open-label, non-randomized, clinical trial was to evaluate the feasibility of trialing ziconotide by intrathecal bolus injections. MATERIAL AND METHODS Twenty-three patients, who had peripheral neuropathic pain refractory to pharmacological treatment and were under consideration for Spinal Cord Stimulation, received up to three ziconotide bolus injections according to a comprehensive algorithm. After a first injection of 2.5 μg, the patients progressed in the algorithm depending on the presence or absence of pain reduction and significant adverse events. A patient was considered a "responder" if experiencing pain reduction and no significant adverse event on two consecutive occasions at the same dosage. RESULTS We found a low proportion of responders (13%). However 30% of patients experienced ≥30% pain reduction on a least one injection, yielding a number needed to treat of ∼3 for clinically significant pain relief. Pain intensity changed significantly over time (0-6 h) (p = 0.047) after a mean ziconotide dose of 2.75 μg. Adverse events were as expected, and no serious adverse event occurred. We did not find any statistical association between response to Spinal Cord Stimulation and response to ziconotide. CONCLUSIONS Ziconotide bolus injection trialing seems feasible, but the proportion of responders in the present study was low. Adverse events were as expected, and no serious adverse event occurred. The predictive power of ziconotide bolus trialing remains unclear, and the pharmacological profile of ziconotide (slow tissue penetration due to high hydrophilicity) calls the rationale for bolus trialing into question.
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Affiliation(s)
- Emmanuel Bäckryd
- Rehabilitation Medicine, Department of Medicine and Health Sciences, Linköping University, Linköping, SE 581 85, Sweden.,Pain and Rehabilitation Centre, UHL, County Council of Östergötland, Linköping, SE 581 85, Sweden
| | - Jan Sörensen
- Rehabilitation Medicine, Department of Medicine and Health Sciences, Linköping University, Linköping, SE 581 85, Sweden.,Pain and Rehabilitation Centre, UHL, County Council of Östergötland, Linköping, SE 581 85, Sweden
| | - Björn Gerdle
- Rehabilitation Medicine, Department of Medicine and Health Sciences, Linköping University, Linköping, SE 581 85, Sweden.,Pain and Rehabilitation Centre, UHL, County Council of Östergötland, Linköping, SE 581 85, Sweden
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Webster LR. The Relationship Between the Mechanisms of Action and Safety Profiles of Intrathecal Morphine and Ziconotide: A Review of the Literature. PAIN MEDICINE 2015; 16:1265-77. [PMID: 25645109 DOI: 10.1111/pme.12666] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To better characterize safety profiles associated with the intrathecal (IT) administration of morphine and ziconotide and discuss how they relate to mechanisms of action. METHODS Published data were evaluated to identify potential relationships between safety profiles of IT morphine and IT ziconotide and their mechanisms of action. RESULTS Potentially severe and clinically relevant adverse events (AEs) associated with IT morphine include respiratory depression, tolerance, and granuloma formulation, whereas IT ziconotide is associated with neuropsychiatric AEs, such as cognitive impairment, hallucinations, and changes in mood or consciousness, particularly with high doses and rapid titration. AEs associated with these IT therapies may result from spread of the medication out of the IT space into areas of the central and peripheral nervous systems and systemic circulation. AEs that occur usually can be managed and, in some cases, prevented. To mitigate risk, patients' histories should be reviewed to identify potential complicating factors (e.g., obesity or other risk factors for respiratory dysfunction in patients receiving IT morphine; a history of psychosis in patients receiving IT ziconotide). Also, treatment should be initiated at a low dose, titrated slowly, and patients should be closely monitored during treatment. CONCLUSIONS IT morphine and IT ziconotide are approved by the US Food and Drug Administration for patients who do not respond to less invasive treatments, but the safety profiles of each may make them more or less appropriate for certain patient populations.
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Hsu E, Murphy S, Chang D, Cohen SP. Expert opinion on emerging drugs: chronic low back pain. Expert Opin Emerg Drugs 2014; 20:103-27. [DOI: 10.1517/14728214.2015.993379] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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11
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Saulino M, Kim PS, Shaw E. Practical considerations and patient selection for intrathecal drug delivery in the management of chronic pain. J Pain Res 2014; 7:627-38. [PMID: 25419158 PMCID: PMC4234284 DOI: 10.2147/jpr.s65441] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Chronic pain continues to pose substantial and growing challenges for patients, caregivers, health care professionals, and health care systems. By the time a patient with severe refractory pain sees a pain specialist for evaluation and management, that patient has likely tried and failed several nonpharmacologic and pharmacologic approaches to pain treatment. Although relegated to one of the interventions of "last resort", intrathecal drug delivery can be useful for improving pain control, optimizing patient functionality, and minimizing the use of systemic pain medications in appropriately selected patients. Due to its clinical and logistical requirements, however, intrathecal drug delivery may fit poorly into the classic pain clinic/interventional model and may be perceived as a "critical mass" intervention that is feasible only for large practices that have specialized staff and appropriate office resources. Potentially, intrathecal drug delivery may be more readily adopted into larger practices that can commit the necessary staff and resources to support patients' needs through the trialing, initiation, monitoring, maintenance, and troubleshooting phases of this therapy. Currently, two agents - morphine and ziconotide - are approved by the United States Food and Drug Administration for long-term intrathecal delivery. The efficacy and safety profiles of morphine have been assessed in long-term, open-label, and retrospective studies of >400 patients with chronic cancer and noncancer pain types. The efficacy and safety profiles of ziconotide have been assessed in three double-blind, placebo-controlled trials of 457 patients, and safety has been assessed in 1,254 patients overall, with severe chronic cancer, noncancer, and acquired immunodeficiency syndrome pain types. Both agents are highlighted as first-line intrathecal therapy for the management of neuropathic or nociceptive pain. The purpose of this review is to discuss practical considerations for intrathecal drug delivery, delineate criteria for the identification and selection of candidates for intrathecal drug delivery, and consider which agent may be more appropriate for individual patients.
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Affiliation(s)
- Michael Saulino
- MossRehab, Elkins Park, PA, USA ; Department of Rehabilitation Medicine, Jefferson Medical College, Philadelphia, PA, USA
| | - Philip S Kim
- Helen F Graham Cancer Center, Christiana Care Health System, Newark, DE, USA ; Center for Interventional Pain Spine, LLC., Bryn Mawr, PA, USA
| | - Erik Shaw
- Shepherd Pain Institute, Shepherd Center, Atlanta, GA, USA
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12
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Bolash R, Mekhail N. Intrathecal pain pumps: indications, patient selection, techniques, and outcomes. Neurosurg Clin N Am 2014; 25:735-42. [PMID: 25240660 DOI: 10.1016/j.nec.2014.06.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intrathecal drug delivery represents an advanced modality for refractory chronic pain patients as well as intractable spasticity. This article reviews the advantages and indications for intrathecal therapy, as well as recommendations for proper patient selection using a multidisciplinary team to provide a global assessment of the impact of chronic pain on the patient's well-being. The goals and expectations of trialing are discussed alongside advantages and disadvantages of several trialing techniques. A discussion of outcomes is presented for patients with chronic pain due to both malignant and nonmalignant causes.
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Affiliation(s)
- Robert Bolash
- Department of Pain Management, Cleveland Clinic, 9500 Euclid Avenue/C25, Cleveland, OH 44195, USA
| | - Nagy Mekhail
- Evidence Based Pain Medicine Research, Department of Pain Management, Cleveland Clinic, 9500 Euclid Avenue/C25, Cleveland, OH 44195, USA.
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13
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Feldman P, Khanna R. Challenging the catechism of therapeutics for chronic neuropathic pain: Targeting CaV2.2 interactions with CRMP2 peptides. Neurosci Lett 2013; 557 Pt A:27-36. [PMID: 23831344 PMCID: PMC3849117 DOI: 10.1016/j.neulet.2013.06.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 06/24/2013] [Accepted: 06/24/2013] [Indexed: 11/25/2022]
Abstract
Chronic neuropathic pain management is a worldwide concern. Pharmaceutical companies globally have historically targeted ion channels as the therapeutic catechism with many blockbuster successes. Remarkably, no new pain therapeutic has been approved by European or American regulatory agencies over the last decade. This article will provide an overview of an alternative approach to ion channel drug discovery: targeting regulators of ion channels, specifically focusing on voltage-gated calcium channels. We will highlight the discovery of an anti-nociceptive peptide derived from a novel calcium channel interacting partner - the collapsin response mediator protein 2 (CRMP2). In vivo administration of this peptide reduces pain behavior in a number of models of neuropathic pain without affecting sympathetic-associated cardiovascular activity, memory retrieval, sensorimotor function, or depression. A CRMP2-derived peptide analgesic, with restricted access to the CNS, represents a completely novel approach to the treatment of severe pain with an improved safety profile. As peptides now represent one of the fastest growing classes of new drugs, it is expected that peptide targeting of protein interactions within the calcium channel complex may be a paradigm shift in ion channel drug discovery.
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Affiliation(s)
- Polina Feldman
- Sophia Therapeutics LLC, 351 West 10th Street, Indianapolis, IN 46202, USA
| | - Rajesh Khanna
- Sophia Therapeutics LLC, 351 West 10th Street, Indianapolis, IN 46202, USA
- Department of Pharmacology and Toxicology, 635 Barnhill Drive, Indianapolis, IN 46202, USA
- Department of Biochemistry and Molecular Biology, 635 Barnhill Drive, Indianapolis, IN 46202, USA
- Program in Medical Neurosciences, Paul and Carole Stark Neurosciences Research Institute, 950 West Walnut Street, Indianapolis, IN 46202, USA
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Hayek SM, Hanes MC. Intrathecal Therapy for Chronic Pain: Current Trends and Future Needs. Curr Pain Headache Rep 2013; 18:388. [DOI: 10.1007/s11916-013-0388-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Sanford M. Intrathecal ziconotide: a review of its use in patients with chronic pain refractory to other systemic or intrathecal analgesics. CNS Drugs 2013; 27:989-1002. [PMID: 23999971 DOI: 10.1007/s40263-013-0107-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Ziconotide (Prialt(®)) is a synthetic conopeptide analgesic that acts by selectively antagonizing N-type voltage-gated calcium channels. Intrathecal ziconotide is the only non-opioid intrathecal analgesic that is FDA-approved for use in patients with treatment-refractory, chronic pain. The efficacy of intrathecal ziconotide was demonstrated in randomized, double-blind, placebo-controlled trials in patients with treatment-refractory noncancer-related pain or cancer- or AIDS-related pain. Across trials, ziconotide recipients had significantly greater reductions in pain intensity during ziconotide treatment than those receiving placebo (primary endpoint). At the end of the titration period, approximately one-sixth to one-third of patients with noncancer chronic pain and one-half with cancer- or AIDS-related pain who received ziconotide reached a pain response threshold (≥30 % reduction in the pain intensity score). In ziconotide responders, analgesic effects were enduring, with some patients continuing treatment over extended periods. Across trials, the chief tolerability concerns in ziconotide recipients during the titration phase and during extended treatment were related to CNS adverse events. These were mostly of mild to moderate intensity, although serious adverse events were commonly attributed to ziconotide treatment, especially in trials with rapid ziconotide titration and that permitted higher dosages. In general, clinically important non-CNS adverse events were infrequent, and during the ziconotide titration phase, relatively few patients discontinued treatment because of adverse events. Ongoing research will assess various strategies for selecting patients for ziconotide treatment and for enhancing its efficacy and tolerability. At the present time, intrathecal ziconotide provides a treatment option for patients with severe, unremitting pain who have failed to respond to other intensive analgesic regimens.
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Affiliation(s)
- Mark Sanford
- Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore, 0754, Auckland, New Zealand,
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16
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Effect of ω-conotoxin MVIIA and Phα1β on paclitaxel-induced acute and chronic pain. Pharmacol Biochem Behav 2013; 114-115:16-22. [PMID: 24148893 DOI: 10.1016/j.pbb.2013.10.014] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 08/31/2013] [Accepted: 10/11/2013] [Indexed: 11/21/2022]
Abstract
The treatment with the chemotherapeutic agent paclitaxel produces a painful peripheral neuropathy, and is associated with an acute pain syndrome in a clinically significant number of patients. However, no standard therapy has been established to manage the acute pain or the chronic neuropathic pain related to paclitaxel. In the present study, we evaluated the analgesic potential of two N-type voltage-gated calcium channel (VGCC) blockers, ω-conotoxin MVIIA and Phα1β, on acute and chronic pain induced by paclitaxel. Adult male rats were treated with four intraperitoneal injections of paclitaxel (1+1+1+1mg/kg, in alternate days) and the development of mechanical hyperalgesia was evaluated 24h (acute painful stage) or 15days (chronic painful stage) after the first paclitaxel injection. Not all animals showed mechanical hyperalgesia 24h after the first paclitaxel injection, but those that showed developed a more intense mechanical hyperalgesia at the chronic painful stage. Intrathecal administration (i.t.) of ω-conotoxin MVIIA (3-300pmol/site) or Phα1β (10-300pmol/site) reduced the mechanical hyperalgesia either at the acute or at the chronic painful stage induced by paclitaxel. When administered at the acute painful stage, ω-conotoxin MVIIA (300pmol/site, i.t.) and Phα1β (300pmol/site, i.t.) prevented the worsening of chronic mechanical hyperalgesia. Furthermore, Phα1β (30-300pmol/site, i.t.) elicited less adverse effects than ω-conotoxin MVIIA (10-300 pmol/site, i.t.). Taken together, our data evidence the involvement of N-type VGCC in pain sensitization induced by paclitaxel and point out the potential of Phα1β as a safer alternative than ω-conotoxin MVIIA to treat the pain related to paclitaxel.
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Bernáldez J, Román-González SA, Martínez O, Jiménez S, Vivas O, Arenas I, Corzo G, Arreguín R, García DE, Possani LD, Licea A. A Conus regularis conotoxin with a novel eight-cysteine framework inhibits CaV2.2 channels and displays an anti-nociceptive activity. Mar Drugs 2013; 11:1188-202. [PMID: 23567319 PMCID: PMC3705398 DOI: 10.3390/md11041188] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 03/05/2013] [Accepted: 03/18/2013] [Indexed: 12/22/2022] Open
Abstract
A novel peptide, RsXXIVA, was isolated from the venom duct of Conus regularis, a worm-hunting species collected in the Sea of Cortez, México. Its primary structure was determined by mass spectrometry and confirmed by automated Edman degradation. This conotoxin contains 40 amino acids and exhibits a novel arrangement of eight cysteine residues (C-C-C-C-CC-CC). Surprisingly, two loops of the novel peptide are highly identical to the amino acids sequence of ω-MVIIA. The total length and disulfide pairing of both peptides are quite different, although the two most important residues for the described function of ω-MVIIA (Lys2 and Tyr13) are also present in the peptide reported here. Electrophysiological analysis using superior cervical ganglion (SCG) neurons indicates that RsXXIVA inhibits CaV2.2 channel current in a dose-dependent manner with an EC50 of 2.8 μM, whose effect is partially reversed after washing. Furthermore, RsXXIVA was tested in hot-plate assays to measure the potential anti-nociceptive effect to an acute thermal stimulus, showing an analgesic effect in acute thermal pain at 30 and 45 min post-injection. Also, the toxin shows an anti-nociceptive effect in a formalin chronic pain test. However, the low affinity for CaV2.2 suggests that the primary target of the peptide could be different from that of ω-MVIIA.
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Affiliation(s)
- Johanna Bernáldez
- Molecular Immunology and Biotoxins Laboratory, Marine Biotechnology Department, Scientific Research and High Education Center from Ensenada (CICESE), Carretera Ensenada-Tijuana #3918, Zona Playitas, Ensenada 22860, Mexico; E-Mails: (J.B.); (O.M.); (S.J.)
| | - Sergio A. Román-González
- Chemistry Biomacromolecules Department, Chemistry Institute, National Autonomous University of Mexico, Av. Universidad 3000, Ciudad Universitaria, PO BOX 70-213, D.F. 04510, Mexico; E-Mails: (S.A.R.-G.); (R.A.)
| | - Oscar Martínez
- Molecular Immunology and Biotoxins Laboratory, Marine Biotechnology Department, Scientific Research and High Education Center from Ensenada (CICESE), Carretera Ensenada-Tijuana #3918, Zona Playitas, Ensenada 22860, Mexico; E-Mails: (J.B.); (O.M.); (S.J.)
| | - Samanta Jiménez
- Molecular Immunology and Biotoxins Laboratory, Marine Biotechnology Department, Scientific Research and High Education Center from Ensenada (CICESE), Carretera Ensenada-Tijuana #3918, Zona Playitas, Ensenada 22860, Mexico; E-Mails: (J.B.); (O.M.); (S.J.)
| | - Oscar Vivas
- Physiology Department, Medicine Faculty, National Autonomous University of Mexico, Av. Universidad 3000, Ciudad Universitaria, PO BOX 70-250, D.F. 04510, Mexico; E-Mails: (O.V.); (I.A.); (D.E.G.)
| | - Isabel Arenas
- Physiology Department, Medicine Faculty, National Autonomous University of Mexico, Av. Universidad 3000, Ciudad Universitaria, PO BOX 70-250, D.F. 04510, Mexico; E-Mails: (O.V.); (I.A.); (D.E.G.)
| | - Gerardo Corzo
- Department of Molecular Medicine and Bioprocesses, National Autonomous University of Mexico, Av. Universidad 2001, C.P. 510-3, Cuernavaca 61500, Mexico; E-Mails: (G.C.); (L.D.P.)
| | - Roberto Arreguín
- Chemistry Biomacromolecules Department, Chemistry Institute, National Autonomous University of Mexico, Av. Universidad 3000, Ciudad Universitaria, PO BOX 70-213, D.F. 04510, Mexico; E-Mails: (S.A.R.-G.); (R.A.)
| | - David E. García
- Physiology Department, Medicine Faculty, National Autonomous University of Mexico, Av. Universidad 3000, Ciudad Universitaria, PO BOX 70-250, D.F. 04510, Mexico; E-Mails: (O.V.); (I.A.); (D.E.G.)
| | - Lourival D. Possani
- Department of Molecular Medicine and Bioprocesses, National Autonomous University of Mexico, Av. Universidad 2001, C.P. 510-3, Cuernavaca 61500, Mexico; E-Mails: (G.C.); (L.D.P.)
| | - Alexei Licea
- Molecular Immunology and Biotoxins Laboratory, Marine Biotechnology Department, Scientific Research and High Education Center from Ensenada (CICESE), Carretera Ensenada-Tijuana #3918, Zona Playitas, Ensenada 22860, Mexico; E-Mails: (J.B.); (O.M.); (S.J.)
- Author to whom correspondence should be addressed; E-Mail: ; Tel./Fax: +52-646-1750-500 (ext. 27201)
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Abstract
INTRODUCTION Ziconotide is an N-type calcium channel antagonist to treat chronic pain that is delivered intrathecally. It is the only intrathecal, FDA-approved, non-opioid analgesic and is recommended as first-line therapy. Despite these advantages, a small therapeutic window limits ziconotide's clinical utility, with adverse event (AE) challenges that include, but are not limited to, dizziness, nausea, and somulence. AREAS COVERED Pharmacokinetics, pharmacodynamics, efficacy, safety, trialing, and chronic infusion after searching EMBASE, PubMed, and Cochrane Database of Systemic Reviews were used to search published literature from 1966 to January 1, 2013 to identify studies related to the intrathecal delivery of ziconotide. EXPERT OPINION Ziconotide is a safe and effective strategy to treat chronic pain, although limitations remain, including a small therapeutic window. Low starting doses and slow incremental increases and long titration intervals may improve tolerability. AEs may be mitigated by also employing combination therapy, although further study is needed. Concomitant use of ziconotide and morphine is an option when considering use of FDA-labeled intrathecal drugs in those resistant to monotherapy.
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Affiliation(s)
- Jason E Pope
- Center for Pain Relief, Inc., 400 Court St, Suite 100, Charleston, WV 25301, USA.
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Michel-Lauter B, Maier C, Schwarzer A. [Accidental levomethadone intoxication in a palliative patient]. Schmerz 2012; 26:721-3. [PMID: 23093298 DOI: 10.1007/s00482-012-1229-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Levomethadone is a strong opioid which is used rarely in the treatment of special pain syndromes in Germany. A main field for the usage of Levomethadone, which has be applied as a oral fluid, is the opioid replacement therapy of heroin-addicts. Due to the long plasma half life and its high inter-individual variability, the application implies a risk of cumulation leading to an overdosage. It is not recommended to use a fixed equianalgesic formula for the dosage conversion from other opioids. The conversion starts with a low start dose, an individual titration follows. In this case-report, the difficulty of cumulation, inaccurate drug dispensary and the characteristic of dosage calculation of levomethadone is discussed.
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Affiliation(s)
- B Michel-Lauter
- Abteilung für Schmerztherapie, Klinik für Anaesthesiologie, Intensiv-, Palliativ- und Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil Bochum GmbH, Bürkle-de-la-Camp-Platz 1, 44789, Bochum, Deutschland.
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Deer TR, Levy R, Prager J, Buchser E, Burton A, Caraway D, Cousins M, De Andrés J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic Consensus Conference--2012: recommendations to reduce morbidity and mortality in intrathecal drug delivery in the treatment of chronic pain. Neuromodulation 2012; 15:467-82; discussion 482. [PMID: 22849581 DOI: 10.1111/j.1525-1403.2012.00486.x] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality. METHODS The Polyanalgesic Consensus Conference is a meeting of experienced implanting physicians who strive to improve care in those receiving implantable devices. Employing data generated through an extensive literature search combined with clinical experience, this work group formulated recommendations regarding awareness, education, and mitigation of the morbidity and mortality associated with intrathecal therapy to establish best practices for targeted intrathecal drug delivery systems. RESULTS Best practices for improved patient care and outcomes with targeted intrathecal infusion are recommended to minimize the risk of morbidity and mortality. Areas of focus include respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error. Specific guidance is given with each of these issues and the general use of the therapy. CONCLUSIONS Targeted intrathecal drug delivery systems are associated with risks for morbidity and mortality that can be devastating. The panel has given guidance to treating physicians and healthcare providers to reduce the incidence of these problems and to improve outcomes when problems occur.
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Deer TR, Prager J, Levy R, Rathmell J, Buchser E, Burton A, Caraway D, Cousins M, De Andrés J, Diwan S, Erdek M, Grigsby E, Huntoon M, Jacobs MS, Kim P, Kumar K, Leong M, Liem L, McDowell GC, Panchal S, Rauck R, Saulino M, Sitzman BT, Staats P, Stanton-Hicks M, Stearns L, Wallace M, Willis KD, Witt W, Yaksh T, Mekhail N. Polyanalgesic Consensus Conference 2012: recommendations for the management of pain by intrathecal (intraspinal) drug delivery: report of an interdisciplinary expert panel. Neuromodulation 2012; 15:436-64; discussion 464-6. [PMID: 22748024 DOI: 10.1111/j.1525-1403.2012.00476.x] [Citation(s) in RCA: 202] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The use of intrathecal (IT) infusion of analgesic medications to treat patients with chronic refractory pain has increased since its inception in the 1980s, and the need for clinical research in IT therapy is ongoing. The Polyanalgesic Consensus Conference (PACC) panel of experts convened in 2000, 2003, and 2007 to make recommendations on the rational use of IT analgesics based on preclinical and clinical literature and clinical experiences. METHODS The PACC panel convened again in 2011 to update the standard of care for IT therapies to reflect current knowledge gleaned from literature and clinical experience. A thorough literature search was performed, and information from this search was provided to panel members. Analysis of published literature was coupled with the clinical experience of panel members to form recommendations regarding the use of IT analgesics to treat chronic pain. RESULTS After a review of literature published from 2007 to 2011 and discussions of clinical experience, the panel created updated algorithms for the rational use of IT medications for the treatment of neuropathic pain and nociceptive pain. CONCLUSIONS The advent of new algorithmic tracks for neuropathic and nociceptive pain is an important step in improving patient care. The panel encourages continued research and development, including the development of new drugs, devices, and safety recommendations to improve the care of patients with chronic pain.
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Abstract
We report on the intrathecal use of ziconotide in three patients with idiopathic facial pain after surgery of the mouth, jaw or face and one patient with neuropathic pain after damage of the lingual nerve. The therapy was successful in three patients but one patient with idiopathic facial pain had pain relief only during the test phase of ziconotide with an external pump and not after implanting the Synchromed® pump. With intrathecal morphine therapy this patient achieved good pain relief. We recommend that patients with neuropathic facial pain should be treated with ziconotide after implementation of guideline-based therapy. In the test phase the ziconotide dose should be increased by 0.6 µg/day per week after an initial dose of 0.6-1.2 µg/day to avoid side-effects.
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