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Pisansky AJB, MacDougall BJ, Ross EL, Chi JH, Neville G, Yaksh TL. Catheter Tip-Associated Mass With Continuous Infusion of Sufentanil for Persistent Spinal Pain Syndrome Type 2: A Case Report Including Histopathologic Examination and Review of the Associated Basic and Clinical Research. Neuromodulation 2024:S1094-7159(24)00031-X. [PMID: 38441505 DOI: 10.1016/j.neurom.2023.12.008] [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: 10/26/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 03/18/2024]
Abstract
OBJECTIVES Intrathecal opioids delivered by implanted pumps are used to treat malignant or nonmalignant chronic pain. In this study, we 1) review a case in which intrathecal infusions of sufentanil along with other adjuvants were used and after an extended period led to an intrathecal mass and 2) compared and contrasted the potential mechanisms for these phenomena. MATERIALS AND METHODS A woman aged 66 years with a history of scoliosis and multiple spine surgeries was treated with an implantable drug delivery system for treating persistent pain after laminectomy. The patient received intrathecal medication comprising sufentanil, bupivacaine, and clonidine. RESULTS Intrathecal therapy over approximately ten years served to reduce pain and improve function over the treatment period. After the extended treatment interval, the patient developed an intrathecal mass that was associated with impairment. The mass was surgically removed. Systematic histopathology revealed the space-occupying mass to largely comprise fibroblasts and some inflammatory cells embedded in a collagen mass located proximally to the catheter tip. CONCLUSIONS To our knowledge, this is the first published case report of sufentanil causing this complication. The science and mechanism of intrathecal catheter tip-associated mass formation and associated clinical research correlates are reviewed in detail, and explanations for this phenomenon are proposed based on histochemical analysis of the patient's pathology findings.
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Affiliation(s)
- Andrew J B Pisansky
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Twin Cities Pain Clinic, Edina, MN, USA
| | - Benjamin J MacDougall
- Division of Pain Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edgar L Ross
- Division of Pain Medicine, Department of Anesthesiology, Brigham and Women's Hospital, Boston, MA, USA
| | - John H Chi
- Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Grace Neville
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Tony L Yaksh
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA.
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Hunt MA, Hunt SAC, Edinger K, Steinauer J, Yaksh TL. Refinement of intrathecal catheter design to enhance neuraxial distribution. J Neurosci Methods 2024; 402:110006. [PMID: 37967672 DOI: 10.1016/j.jneumeth.2023.110006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/11/2023] [Accepted: 11/09/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND Delivery of therapeutics via indwelling intrathecal catheters is highly efficacious for targeting of pain, spasticity, neuraxial cancer and neurodegenerative disorders. However, current catheter designs have some major limitations. Given limited CSF flow, fixed intrathecal volume and the large distance of the rostro-caudal spinal axis, current intrathecal delivery routes fail to achieve adequate drug distribution. Additionally open catheter systems are plagued with cellular ingrowth and debris accumulation if used intermittently. NEW METHOD RESULTS/COMPARISON WITH EXISTING METHOD(S): High speed imaging showed micro-valve catheters greatly increase fluid exit velocities compared to typical open-ended catheters, which prevents pooling of injectate proximal to the opening. When implanted intrathecally in rats, small injection volumes (7.5 μL) of dye or AAV9-RFP, resulted in an even rostro-caudal distribution along the spinal axis and robust transfection of neurons from cervical to lumbar dorsal root ganglia. In contrast, such injections with an open-ended catheter resulted in localized distribution and transfection proximal to the delivery site. Our poly micro-valve catheter design resulted in equivalent transfection rates of cervical DRG neurons using 100x lower titer of AAV9-RFP. Unlike open port catheters, no debris accumulation was observed in the lumen of implanted catheters, showing potential for long-term intermittent use. CONCLUSIONS This catheter platform, suitable for small animal models is easily scalable for human use and addresses many of the problems observed with common catheter systems.
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Affiliation(s)
- Matthew A Hunt
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Sara A C Hunt
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Kelly Edinger
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Joanne Steinauer
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States
| | - Tony L Yaksh
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093, United States; Department of Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, United States.
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Yaksh TL, Santos GGD, Borges Paes Lemes J, Malange K. Neuraxial drug delivery in pain management: An overview of past, present, and future. Best Pract Res Clin Anaesthesiol 2023; 37:243-265. [PMID: 37321769 DOI: 10.1016/j.bpa.2023.04.003] [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: 04/05/2023] [Accepted: 04/11/2023] [Indexed: 06/17/2023]
Abstract
Activation of neuraxial nociceptive linkages leads to a high level of encoding of the message that is transmitted to the brain and that can initiate a pain state with its attendant emotive covariates. As we review here, the encoding of this message is subject to a profound regulation by pharmacological targeting of dorsal root ganglion and dorsal horn systems. Though first shown with the robust and selective modulation by spinal opiates, subsequent work has revealed the pharmacological and biological complexity of these neuraxial systems and points to several regulatory targets. Novel therapeutic delivery platforms, such as viral transfection, antisense and targeted neurotoxins, point to disease-modifying approaches that can selectively address the acute and chronic pain phenotype. Further developments are called for in delivery devices to enhance local distribution and to minimize concentration gradients, as frequently occurs with the poorly mixed intrathecal space. The field has advanced remarkably since the mid-1970s, but these advances must always address the issues of safety and tolerability of neuraxial therapy.
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Affiliation(s)
- Tony L Yaksh
- Department of Anesthesiology University of California, San Diego, San Diego CA, 92103, USA.
| | | | | | - Kaue Malange
- Department of Anesthesiology University of California, San Diego, San Diego CA, 92103, USA
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Kokubu S, Eddinger KA, Yamaguchi S, Huerta-Esquivel LL, Schiller PW, Yaksh TL. Characterization of Analgesic Actions of the Chronic Intrathecal Infusion of H-Dmt-D-Arg-Phe-Lys-NH2 in Rat. Neuromodulation 2019; 22:781-789. [PMID: 30794333 PMCID: PMC6706328 DOI: 10.1111/ner.12925] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 11/27/2018] [Accepted: 12/31/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVES DMT-DALDA (H-Dmt-D-Arg-Phe-Lys-NH2; Dmt = 2',6'-dimethyltyrosine) is a selective mu opioid agonist. We sought to characterize efficacy, tolerance, dependence and side-effect profile when given by continuous intrathecal infusion. MATERIALS AND METHODS Adult male Sprague Dawley rats were prepared with chronic intrathecal catheters and osmotic mini-pumps to deliver vehicle (saline), DMT-DALDA or morphine. Hind paw thermal escape latencies were assessed. In addition, effects upon intraplantar formalin-evoked flinching and withdrawal after 14 days of infusion were examined. The flare response after intradermal delivery was examined in the canine model. RESULTS 1) Intrathecal infusion of 0.3 to 30 pmol/μL/hour of DMT-DALDA or 37.5 nmol/μL/hour of morphine more than 7 or 14 days resulted in a dose-dependent increase in thermal escape latency. The maximum antinociceptive effect was observed between 1 and 4 days after start of infusion with preserved cornea, blink, placing and stepping. By days 12 to 14, response latencies were below baseline. 2) On days 2 to 4 of DMT-DALDA infusion, the pan opioid receptor antagonist naloxone (Nx), but not the delta-preferring antagonist naltrindole, antagonized the analgesic effects. 3) Assessment of formalin flinching on day 1 following IT DMT-DALDA Infusion showed significant analgesia in phases 1 and 2. On day 6 of infusion there was minimal effect, while on day 13, there was an increase in flinching. 4) On days 7 and 14 of infusion Nx resulted in prominent withdrawal signs indicating dependence and withdrawal. 5) Intradermal morphine and DMT-DALDA both yield a naltrexone-insensitive, cromolyn-sensitive flare in the canine model at similar concentrations. CONCLUSIONS These data suggest that DMT-DALDA is a potent, spinally active agonist with a propensity to produce tolerance dependence and mast cell degranulation. While it was equiactive to morphine in producing mast cell degranulation, it was >1000 fold more potent in producing analgesia, suggesting a possible lower risk in producing a spinal mass at equianalgesic doses.
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Affiliation(s)
- Shinichi Kokubu
- Department of Anesthesiology, University of California San Diego, U.S.A
- Department of Anesthesiology, Dokkyo Medical University, Tochigi, Japan
| | - Kelly A. Eddinger
- Department of Anesthesiology, University of California San Diego, U.S.A
| | - Shigeki Yamaguchi
- Department of Anesthesiology, Dokkyo Medical University, Tochigi, Japan
| | - Lena Libertad Huerta-Esquivel
- Department of Anesthesiology, University of California San Diego, U.S.A
- Université de Strasbourg, CEDEX Estrasburgo, Alsacia, France
- Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Nuevo Leon, Mexico
| | - Peter W. Schiller
- Department of Pharmacology and Physiology, University of Montreal, Quebec, Canada
- Montreal Clinical Research Institute, Montreal, Quebec, Canada
| | - Tony L. Yaksh
- Department of Anesthesiology, University of California San Diego, U.S.A
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Zhang T, Liu R, Che D, Pundir P, Wang N, Han S, Cao J, Lv Y, Dong H, Fang F, Wang J, Ma P, Zhao T, Lei T, Dong X, He L. A Mast Cell–Specific Receptor Is Critical for Granuloma Induced by Intrathecal Morphine Infusion. THE JOURNAL OF IMMUNOLOGY 2019; 203:1701-1714. [DOI: 10.4049/jimmunol.1801423] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 08/01/2019] [Indexed: 01/22/2023]
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Yaksh TL, Eddinger KA, Kokubu S, Wang Z, DiNardo A, Ramachandran R, Zhu Y, He Y, Weren F, Quang D, Malkmus SA, Lansu K, Kroeze WK, Eliceiri B, Steinauer JJ, Schiller PW, Gmeiner P, Page LM, Hildebrand KR. Mast Cell Degranulation and Fibroblast Activation in the Morphine-induced Spinal Mass: Role of Mas-related G Protein-coupled Receptor Signaling. Anesthesiology 2019; 131:132-147. [PMID: 31225809 PMCID: PMC6590697 DOI: 10.1097/aln.0000000000002730] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND As the meningeally derived, fibroblast-rich, mass-produced by intrathecal morphine infusion is not produced by all opiates, but reduced by mast cell stabilizers, the authors hypothesized a role for meningeal mast cell/fibroblast activation. Using the guinea pig, the authors asked: (1) Are intrathecal morphine masses blocked by opiate antagonism?; (2) Do opioid agonists not producing mast cell degranulation or fibroblast activation produce masses?; and (3) Do masses covary with Mas-related G protein-coupled receptor signaling thought to mediate mast cell degranulation? METHODS In adult male guinea pigs (N = 66), lumbar intrathecal catheters connected to osmotic minipumps (14 days; 0.5 µl/h) were placed to deliver saline or equianalgesic concentrations of morphine sulfate (33 nmol/h), 2',6'-dimethyl tyrosine-(Tyr-D-Arg-Phe-Lys-NH2) (abbreviated as DMT-DALDA; 10 pmol/h; μ agonist) or PZM21 (27 nmol/h; biased μ agonist). A second pump delivered subcutaneous naltrexone (25 µg/h) in some animals. After 14 to 16 days, animals were anesthetized and perfusion-fixed. Drug effects on degranulation of human cultured mast cells, mouse embryonic fibroblast activation/migration/collagen formation, and Mas-related G protein-coupled receptor activation (PRESTO-Tango assays) were determined. RESULTS Intrathecal infusion of morphine, DMT-DALDA or PZM21, but not saline, comparably increased thermal thresholds for 7 days. Spinal masses proximal to catheter tip, composed of fibroblast/collagen type I (median: interquartile range, 0 to 4 scale), were produced by morphine (2.3: 2.0 to 3.5) and morphine plus naltrexone (2.5: 1.4 to 3.1), but not vehicle (1.2: 1.1 to 1.5), DMT-DALDA (1.0: 0.6 to 1.3), or PZM21 (0.5: 0.4 to 0.8). Morphine in a naloxone-insensitive fashion, but not PZM21 or DMT-DALDA, resulted in mast cell degranulation and fibroblast proliferation/collagen formation. Morphine-induced fibroblast proliferation, as mast cell degranulation, is blocked by cromolyn. Mas-related G protein-coupled receptor activation was produced by morphine and TAN67 (∂-opioid agonist), but not by PZM21, TRV130 (mu biased ligand), or DMT-DALDA. CONCLUSIONS Opiates that activate Mas-related G protein-coupled receptor will degranulate mast cells, activate fibroblasts, and result in intrathecal mass formation. Results suggest a mechanistically rational path forward to safer intrathecal opioid therapeutics.
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Affiliation(s)
- Tony L Yaksh
- From the Laboratory of Anesthesiology Research, Department of Anesthesiology (T.L.Y., K.A.E., S.K., R.R., Y.Z., Y.H., F.W., D.Q., S.A.M., J.J.S.) Department of Dermatology (Z.W., A.D.) Division of Trauma, Department of Surgery (B.P.E.), University of California, San Diego, California the Department of Pharmacology, University of North Carolina-Chapel Hill, Chapel Hill, North Carolina (K.L., W.K.K) Montreal Clinical Research Institute and the Department of Pharmacology and Physiology, University of Montreal, Quebec, Canada (P.W.S.) Department of Chemistry and Pharmacy, Friedrich-Alexander University Erlangen-Nurnberg, Erlangen, Germany (P.G.) Implantables Research and Technology, Medtronic, Inc., Restorative Therapies Group, Minneapolis, Minnesota (L.M.P., K.R.H.)
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Hildebrand KR, Page LM, Billstrom TM, Steinauer JJ, Eddinger KA, Arjomand S, Yaksh TL. Characterization of Effect of Repeated Bolus or Continuous Intrathecal Infusion of Morphine on Spinal Mass Formation in the Dog. Neuromodulation 2019; 22:790-798. [PMID: 31124198 DOI: 10.1111/ner.12963] [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: 11/28/2018] [Revised: 02/22/2019] [Accepted: 03/21/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND We determined whether intrathecally delivering the same daily dose of morphine (MS) at a fixed concentration of 25 mg/mL by periodic boluses versus continuous infusion would reduce intrathecal mass (IMs) formation in dogs. METHODS Adult dogs (hound cross, n = 32) were implanted with intrathecal catheters connected to SynchroMed II infusion pumps. Animals were randomly assigned to receive infusion of 0.48 mL/day of saline or MS dosing (12 mg/day at 25 mg/mL) as boluses: x1 (q24hour), x2 (q12hour), x4 (q6hour), or x8 (q3hour) given at the rate of 1000 μL/hour, or as a continuous infusion (25 mg/mL/20 μL/hour). RESULTS With IT saline, minimal pathology was noted. In contrast, animals receiving morphine displayed spinally compressing durally derived masses with the maximal cross-sectional area being greatest near the catheter tip. Histopathology showed that IMs consisted of fibroblasts in a collagen (type 1) matrix comprised of newly formed collagen near the catheter and mature collagen on the periphery of the mass. The rank order of median cross-sectional mass area (mm2 ) was: Saline: 0.7 mm2 ; x2: 1.8 mm2 ; x4: 2.7 mm2 ; x1: 2.7 mm2 ; x8: 4.2 mm2 ; Continuous: 8.1 mm2 , with statistical difference from saline being seen with continuous (p < 0.0001) and x8 (p < 0.05). Bench studies with a 2D diffusion chamber confirmed an increase in dye distribution and lower peak concentrations after bolus delivery versus continuous infusion of dye. CONCLUSIONS Using multiple bolus dosing, IMs were reduced as compared to continuous infusion, suggesting relevance of bolus delivery in yielding reduced intrathecal masses.
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Affiliation(s)
- Keith R Hildebrand
- Medtronic, Restorative Therapies Group, Targeted Drug Delivery, Minneapolis, MN, USA
| | - Linda M Page
- Medtronic, Restorative Therapies Group, Targeted Drug Delivery, Minneapolis, MN, USA
| | - Tina M Billstrom
- Medtronic Physiological Research Laboratories, Coon Rapid, MN, USA
| | - Joanne J Steinauer
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Kelly A Eddinger
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Shervin Arjomand
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | - Tony L Yaksh
- Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
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Yaksh TL. Letter to Editor re: “Unique Intradural Inflammatory Mass Containing Precipitated Morphine” by Kim et al. Pain Pract 2019; 19:456. [DOI: 10.1111/papr.12761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tony L. Yaksh
- Departments of Anesthesiology, and Pharmacology University of California, San Diego La Jolla California U.S.A
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Dhar D, Poree LR, Yaksh TL. Evolution of the Spinal Delivery of Opiate Analgesics. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00065-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Schmidt-Rondon E, Wang Z, Malkmus SA, Di Nardo A, Hildebrand K, Page L, Yaksh TL. Effects of opioid and nonopioid analgesics on canine wheal formation and cultured human mast cell degranulation. Toxicol Appl Pharmacol 2018; 338:54-64. [PMID: 29111148 PMCID: PMC9841896 DOI: 10.1016/j.taap.2017.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/10/2017] [Accepted: 10/20/2017] [Indexed: 02/06/2023]
Abstract
Mast cell (MC) degranulation has been implicated in the side effect profile of a variety of clinically useful agents. Thus, after intrathecal delivery, formation of space-occupying, meningeally-derived masses may be related to local MC degranulation. We systematically characterized degranulating effects of opioid and nonopioid analgesics on cutaneous flares in the dog and in primary human MC (hMC) cultures. METHODS Dogs were anesthetized with IV propofol and received intradermal (ID) injections (50μL). Flare diameters were measured at 30min. Drugs showing flare responses were tested after intramuscular (IM) cromolyn (10mg/kg), a MC stabilizer. Human primary MCs (human cord blood CD34+/CD45+ cells) were employed and β-hexosaminidase in cell-free supernatants were measured to assess degranulation. RESULTS A significant skin flare for several classes of agents was observed including opioids, ziconotide, ketamine, ST-91, neostigmine, adenosine, bupivacaine, lidocaine, MK-801 and 48/80. Tizanidine, fentanyl, alfentanil, gabapentin and baclofen produced no flare. Flare produced by all ID agents, except adenosine, bupivacaine and lidocaine, was reduced by cromolyn. Naloxone had no effect upon opiate or 48/80 evoked flares. In hMC studies, 48/80 resulted in a concentration-dependent release of β-hexosaminidase. The rank order of drug-induced hMC β-hexosaminidase release was similar to that for flares. CONCLUSIONS A variety of therapeutically useful drugs degranulate MCs. This action may account for side effects such as the intrathecal granuloma resulting from spinally-delivered opioids. This degranulating effect may be useful in predicting potential intrathecal toxicity in the development of novel agents.
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Affiliation(s)
- Eric Schmidt-Rondon
- Department of Anesthesiology, University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, United States
| | - Zhenping Wang
- Department of Dermatology, University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, United States
| | - Shelle A. Malkmus
- Department of Anesthesiology, University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, United States
| | - Anna Di Nardo
- Department of Dermatology, University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, United States
| | - Keith Hildebrand
- Medtronic, Inc., Neuromodulation, 7000 Central Avenue NE, RCE470, Minneapolis, MN 55432, United States
| | - Linda Page
- Medtronic, Inc., Neuromodulation, 7000 Central Avenue NE, RCE470, Minneapolis, MN 55432, United States
| | - Tony L. Yaksh
- Department of Anesthesiology, University of California, San Diego, 9500 Gilman Dr., La Jolla, CA 92093, United States,Corresponding author at: Department of Anesthesiology 0818, University of California, San Diego, 9500 Gilman Drive, San Diego, CA 92093-0818, United States, (T.L. Yaksh)
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Emami A, Tepper J, Short B, Yaksh TL, Bendele AM, Ramani T, Cisternas AF, Chang JH, Mellon RD. Toxicology Evaluation of Drugs Administered via Uncommon Routes: Intranasal, Intraocular, Intrathecal/Intraspinal, and Intra-Articular. Int J Toxicol 2017; 37:4-27. [PMID: 29264927 DOI: 10.1177/1091581817741840] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
As the need for nasal, ocular, spinal, and articular therapeutic compounds increases, toxicology assessments of drugs administered via these routes play an important role in human safety. This symposium outlined the local and systemic evaluation to support safety during the development of these drugs in nonclinical models with some case studies. Discussions included selection of appropriate species for the intended route; conducting nonclinical studies that closely mimic the intended use with adequate duration; functional assessment, if deemed necessary; evaluation of local tissues with special histological staining procedure; and evaluations of safety margins based on local and systemic toxicity.
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Affiliation(s)
- Armaghan Emami
- 1 US Food and Drug Administration, Silver Spring, MD, USA
| | - Jeff Tepper
- 2 Tepper Nonclinical Consulting, San Carlos, CA, USA
| | - Brian Short
- 3 Brian Short Consulting, LLC, Trabuco Canyon, CA, USA
| | - Tony L Yaksh
- 4 Department of Anesthesiology, University of California, San Diego, La Jolla, CA, USA
| | | | | | | | - Jay H Chang
- 1 US Food and Drug Administration, Silver Spring, MD, USA
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Deer TR, Pope JE, Hayek SM, Lamer TJ, Veizi IE, Erdek M, Wallace MS, Grider JS, Levy RM, Prager J, Rosen SM, Saulino M, Yaksh TL, De Andrés JA, Abejon Gonzalez D, Vesper J, Schu S, Simpson B, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks. Neuromodulation 2017; 20:155-176. [DOI: 10.1111/ner.12579] [Citation(s) in RCA: 99] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 11/22/2016] [Accepted: 12/07/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | | | - Salim M. Hayek
- University Hospitals Cleveland Medical Center, Case Western Reserve University; Cleveland OH USA
| | | | - Ilir Elias Veizi
- Veterans Administration Medical Center, Case Western Reserve University; Cleveland OH USA
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- UK HealthCare Pain Services, University of Kentucky College of Medicine; Lexington KY USA
| | | | - Joshua Prager
- Center for the Rehabilitation of Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology, University of California; San Diego CA USA
| | - Jose A. De Andrés
- Valencia School of Medicine, Hospital General Universitario; Valencia Spain
| | | | - Jan Vesper
- Neurochirurgische Klinik, Universitätsklinikum Düsseldorf; Germany
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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