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Lin J, Chen S, Butt UD, Yan M, Wu B. A comprehensive review on ziconotide. Heliyon 2024; 10:e31105. [PMID: 38779019 PMCID: PMC11110537 DOI: 10.1016/j.heliyon.2024.e31105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Managing severe chronic pain is a challenging task, given the limited effectiveness of available pharmacological and non-pharmacological treatments. This issue continues to be a significant public health concern, requiring a substantial therapeutic response. Ziconotide, a synthetic peptide initially isolated from Conus magus in 1982 and approved by the US Food and Drug Administration and the European Medicines Agency in 2004, is the first-line intrathecal method for individuals experiencing severe chronic pain refractory to other therapeutic measures. Ziconotide produces powerful analgesia by blocking N-type calcium channels in the spinal cord, which inhibits the release of pain-relevant neurotransmitters from the central terminals of primary afferent neurons. However, despite possessing many favorable qualities, including the absence of tolerance development, respiratory depression, and withdrawal symptoms (largely due to the absence of a G-protein mediation mechanism), ziconotide's application is limited due to factors such as intrathecal administration and a narrow therapeutic window resulting from significant dose-related undesired effects of the central nervous system. This review aims to provide a comprehensive and clinically relevant summary of the literatures concerning the pharmacokinetics and metabolism of intrathecal ziconotide. It will also describe strategies intended to enhance clinical efficacy while reducing the incidence of side effects. Additionally, the review will explore the current efforts to refine the structure of ziconotide for better clinical outcomes. Lastly, it will prospect potential developments in the new class of selective N-type voltage-sensitive calcium-channel blockers.
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Affiliation(s)
- Jinping Lin
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, China
| | - Shuwei Chen
- Fuyang People's Hospital, Hangzhou 311400, China
| | | | - Min Yan
- Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310000, China
| | - Bin Wu
- Ocean College, Zhejiang University, Zhoushan 321000, China
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2
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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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3
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Sayed D, Grider J, Strand N, Hagedorn JM, Falowski S, Lam CM, Tieppo Francio V, Beall DP, Tomycz ND, Davanzo JR, Aiyer R, Lee DW, Kalia H, Sheen S, Malinowski MN, Verdolin M, Vodapally S, Carayannopoulos A, Jain S, Azeem N, Tolba R, Chang Chien GC, Ghosh P, Mazzola AJ, Amirdelfan K, Chakravarthy K, Petersen E, Schatman ME, Deer T. The American Society of Pain and Neuroscience (ASPN) Evidence-Based Clinical Guideline of Interventional Treatments for Low Back Pain. J Pain Res 2022; 15:3729-3832. [PMID: 36510616 PMCID: PMC9739111 DOI: 10.2147/jpr.s386879] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction Painful lumbar spinal disorders represent a leading cause of disability in the US and worldwide. Interventional treatments for lumbar disorders are an effective treatment for the pain and disability from low back pain. Although many established and emerging interventional procedures are currently available, there exists a need for a defined guideline for their appropriateness, effectiveness, and safety. Objective The ASPN Back Guideline was developed to provide clinicians the most comprehensive review of interventional treatments for lower back disorders. Clinicians should utilize the ASPN Back Guideline to evaluate the quality of the literature, safety, and efficacy of interventional treatments for lower back disorders. Methods The American Society of Pain and Neuroscience (ASPN) identified an educational need for a comprehensive clinical guideline to provide evidence-based recommendations. Experts from the fields of Anesthesiology, Physiatry, Neurology, Neurosurgery, Radiology, and Pain Psychology developed the ASPN Back Guideline. The world literature in English was searched using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Scopus, and meeting abstracts to identify and compile the evidence (per section) for back-related pain. Search words were selected based upon the section represented. Identified peer-reviewed literature was critiqued using United States Preventive Services Task Force (USPSTF) criteria and consensus points are presented. Results After a comprehensive review and analysis of the available evidence, the ASPN Back Guideline group was able to rate the literature and provide therapy grades to each of the most commonly available interventional treatments for low back pain. Conclusion The ASPN Back Guideline represents the first comprehensive analysis and grading of the existing and emerging interventional treatments available for low back pain. This will be a living document which will be periodically updated to the current standard of care based on the available evidence within peer-reviewed literature.
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Affiliation(s)
- Dawood Sayed
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA,Correspondence: Dawood Sayed, The University of Kansas Health System, 3901 Rainbow Blvd, Kansas City, KS, 66160, USA, Tel +1 913-588-5521, Email
| | - Jay Grider
- University of Kentucky, Lexington, KY, USA
| | - Natalie Strand
- Interventional Pain Management, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Steven Falowski
- Functional Neurosurgery, Neurosurgical Associates of Lancaster, Lancaster, PA, USA
| | - Christopher M Lam
- Department of Anesthesiology and Pain Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - Vinicius Tieppo Francio
- Department of Rehabilitation Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nestor D Tomycz
- AHN Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Rohit Aiyer
- Interventional Pain Management and Pain Psychiatry, Henry Ford Health System, Detroit, MI, USA
| | - David W Lee
- Physical Medicine & Rehabilitation and Pain Medicine, Fullerton Orthopedic Surgery Medical Group, Fullerton, CA, USA
| | - Hemant Kalia
- Rochester Regional Health System, Rochester, NY, USA,Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Soun Sheen
- Department of Physical Medicine & Rehabilitation, University of Rochester, Rochester, NY, USA
| | - Mark N Malinowski
- Adena Spine Center, Adena Health System, Chillicothe, OH, USA,Ohio University Heritage College of Osteopathic Medicine, Athens, OH, USA
| | - Michael Verdolin
- Anesthesiology and Pain Medicine, Pain Consultants of San Diego, San Diego, CA, USA
| | - Shashank Vodapally
- Physical Medicine and Rehabilitation, Michigan State University, East Lansing, MI, USA
| | - Alexios Carayannopoulos
- Department of Physical Medicine and Rehabilitation, Rhode Island Hospital, Newport Hospital, Lifespan Physician Group, Providence, RI, USA,Comprehensive Spine Center at Rhode Island Hospital, Newport Hospital, Providence, RI, USA,Neurosurgery, Brown University, Providence, RI, USA
| | - Sameer Jain
- Interventional Pain Management, Pain Treatment Centers of America, Little Rock, AR, USA
| | - Nomen Azeem
- Department of Neurology, University of South Florida, Tampa, FL, USA,Florida Spine & Pain Specialists, Riverview, FL, USA
| | - Reda Tolba
- Pain Management, Cleveland Clinic, Abu Dhabi, United Arab Emirates,Anesthesiology, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - George C Chang Chien
- Pain Management, Ventura County Medical Center, Ventura, CA, USA,Center for Regenerative Medicine, University Southern California, Los Angeles, CA, USA
| | | | | | | | - Krishnan Chakravarthy
- Division of Pain Medicine, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA,Va San Diego Healthcare, San Diego, CA, USA
| | - Erika Petersen
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, AR, USA
| | - Michael E Schatman
- Department of Anesthesiology, Perioperative Care, and Pain Medicine, NYU Grossman School of Medicine, New York, New York, USA,Department of Population Health - Division of Medical Ethics, NYU Grossman School of Medicine, New York, New York, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
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Jergova S, Hernandez M, Sagen J. Analgesic effect of recombinant GABAergic precursors releasing MVIIA in a model of peripheral nerve injury in rats. Mol Pain 2022; 18:17448069221129829. [PMID: 36113096 PMCID: PMC9513588 DOI: 10.1177/17448069221129829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Development of chronic pain has been attributed to dysfunctional GABA signaling in the
spinal cord. Direct pharmacological interventions on GABA signaling are usually not very
efficient and often accompanied by side effects due to the widespread distribution of GABA
receptors in CNS. Transplantation of GABAergic neuronal cells may restore the inhibitory
potential in the spinal cord. Grafted cells may also release additional analgesic peptides
by means of genetic engineering to further enhance the benefits of this approach.
Conopeptides are ideal candidates for recombinant expression using cell-based strategies.
The omega-conopeptide MVIIA is in clinical use for severe pain marketed as FDA approved
Prialt in the form of intrathecal injections. The goal of this study was to develop
transplantable recombinant GABAergic cells releasing conopeptide MVIIA and to evaluate the
analgesic effect of the grafts in a model of peripheral nerve injury-induced pain. We have
engineered and characterized the GABAergic progenitors expressing MVIIA. Recombinant and
nonrecombinant cells were intraspinally injected into animals after the nerve injury.
Animals were tested weekly up to 12 weeks for the presence of hypersensitivity, followed
by histochemical and biochemical analysis of the tissue. We observed beneficial effects of
the grafted cells in reducing hypersensitivity in all grafted animals, especially potent
in the recombinant group. The level of pain-related cytokines was reduced in the grafted
animals and correlation between these pain markers and actual behavior was indicated. This
study demonstrated the feasibility of recombinant cell transplantation in the management
of chronic pain.
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Micheli L, Lucarini E, Toti A, Ferrara V, Ciampi C, Parisio C, Bartolucci G, Di Cesare Mannelli L, Ghelardini C. Effects of Ultramicronized N-Palmitoylethanolamine Supplementation on Tramadol and Oxycodone Analgesia and Tolerance Prevention. Pharmaceutics 2022; 14:pharmaceutics14020403. [PMID: 35214131 PMCID: PMC8875545 DOI: 10.3390/pharmaceutics14020403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023] Open
Abstract
Chronic pain management requires increasing doses of opioids, the milestone of painkillers, which may result in the onset of tolerance with exacerbated side effects. Maintaining stable analgesia with low doses of opioids is thus imperative. N-palmitoylethanolamine (PEA) is an endogenous lipid compound endowed with pain-relieving as well as anti-inflammatory properties. The ultramicronized formulation of PEA was recently demonstrated to be able to modulate morphine’s effects, delaying tolerance and improving efficacy. To evaluate the possible application to other opioids, in this study, we analysed the capacity of ultramicronized PEA to regulate analgesia and tolerance induced by oxycodone and tramadol. Pre-emptive and continuative treatment with ultramicronized PEA (30 mg kg−1, daily, per os) delayed the onset of opioid tolerance and enhanced opioid analgesia when it was acutely administered in association with tramadol (20 mg kg−1, daily, subcutaneously) or oxycodone (0.5 mg kg−1, daily, subcutaneously). Moreover, PEA exerted antinociceptive effects on tolerant rats, suggesting the use of PEA together with opioids for stable, long-lasting analgesia. To that purpose, the oxycodone dose needed to be increased from 0.3 mg kg−1 (day 1) up to 1 mg kg−1 (day 31) in the oxycodone + vehicle group; the tramadol dose was progressively enhanced from 15 mg kg−1 to 50 mg kg−1 in 31 days in the tramadol + vehicle group. Acute oral co-treatment with PEA (120 mg kg−1) achieved the same analgesia without increasing the dose of both opioids. The behavioural effects of PEA on opioid chronic treatment paralleled a decrease in astrocyte activation in the dorsal horn of the spinal cord (a marker of the development of opioid tolerance) and with a modulation of mRNA expression of IL-6 and serpin-A3. In conclusion, pre- and co-administration of ultramicronized PEA delayed the development of tramadol tolerance, potentiating either oxycodone or tramadol analgesia and allowing a long-lasting analgesic effect with a low opioid dose regimen. The use of PEA is suggested for clinical purposes to support the opioid-based management of persistent pain.
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Affiliation(s)
- Laura Micheli
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
| | - Elena Lucarini
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
| | - Alessandra Toti
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
| | - Valentina Ferrara
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
| | - Clara Ciampi
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
| | - Carmen Parisio
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
| | - Gianluca Bartolucci
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmaceutical and Nutraceutical Sciences Section, University of Florence, 50019 Florence, Italy;
| | - Lorenzo Di Cesare Mannelli
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
- Correspondence: ; Tel.: +39-055-2758-395
| | - Carla Ghelardini
- Department of Neuroscience, Psychology, Drug Research and Child Health-Neurofarba-Pharmacology and Toxicology Section, University of Florence, 50139 Florence, Italy; (L.M.); (E.L.); (A.T.); (V.F.); (C.C.); (C.P.); (C.G.)
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Physicochemical Stability Study of the Morphine-Ropivacaine-Ziconotide Association in Implantable Pumps for Intrathecal Administration. Neuromodulation 2022:S1094-7159(21)06177-8. [PMID: 35088750 DOI: 10.1016/j.neurom.2021.10.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE This study aimed to investigate the physicochemical stability of morphine-ropivacaine-ziconotide mixtures used in intrathecal analgesia. MATERIALS AND METHODS Eight mixtures were studied to assess their stability profiles according to the initial drug concentrations used. The solutions obtained were put in implantable pumps and stored at 37 °C over a period of 60 days. Assays were performed using ultra high-pressure liquid chromatography. Turbidity and pH were also measured throughout the study. RESULTS Results confirmed excellent physicochemical stability for morphine and ropivacaine. Concerning ziconotide, three of the eight mixtures did not show any sign of chemical instability: average concentrations remained constant throughout the 60 days. A decrease of the concentration was observed for the five other mixtures. Moreover, the appearance of a degradation product linked to oxidation confirmed the ziconotide degradation. CONCLUSIONS All these results are in favor of a physicochemical stable preparation for three of the mixture profiles when stored in implantable pumps at 37 °C up to 60 days. For the five others, the efficacy should decrease over time owing to the degradation of ziconotide. The decrease in kinetics of the ziconotide concentration depends on the mixing profile. One possibility is to adapt the filling intervals according to the profile of the mixture. Finally, the results show the period of stability ensuring maximum analgesic efficacy for the eight mixture profiles studied.
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7
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da Silva JF, Binda NS, Pereira EMR, de Lavor MSL, Vieira LB, de Souza AH, Rigo FK, Ferrer HT, de Castro CJ, Ferreira J, Gomez MV. Analgesic effects of Phα1β toxin: a review of mechanisms of action involving pain pathways. J Venom Anim Toxins Incl Trop Dis 2021; 27:e20210001. [PMID: 34868281 PMCID: PMC8610172 DOI: 10.1590/1678-9199-jvatitd-2021-0001] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/26/2021] [Indexed: 01/01/2023] Open
Abstract
Phα1β is a neurotoxin purified from spider venom that acts as a high-voltage-activated (HVA) calcium channel blocker. This spider peptide has shown a high selectivity for N-type HVA calcium channels (NVACC) and an analgesic effect in several animal models of pain. Its activity was associated with a reduction in calcium transients, glutamate release, and reactive oxygen species production from the spinal cord tissue and dorsal ganglia root (DRG) in rats and mice. It has been reported that intrathecal (i.t.) administration of Phα1β to treat chronic pain reverted opioid tolerance with a safer profile than ω-conotoxin MVIIA, a highly selective NVACC blocker. Following a recent development of recombinant Phα1β (CTK 01512-2), a new molecular target, TRPA1, the structural arrangement of disulphide bridges, and an effect on glial plasticity have been identified. CTK 01512-2 reproduced the antinociceptive effects of the native toxin not only after the intrathecal but also after the intravenous administration. Herein, we review the Phα1β antinociceptive activity in the most relevant pain models and its mechanisms of action, highlighting the impact of CTK 01512-2 synthesis and its potential for multimodal analgesia.
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Affiliation(s)
- Juliana Figueira da Silva
- Laboratory of Pharmacology, Department of Pharmacy, Federal
University of Ouro Preto, Ouro Preto, MG, Brazil
| | - Nancy Scardua Binda
- Laboratory of Pharmacology, Department of Pharmacy, Federal
University of Ouro Preto, Ouro Preto, MG, Brazil
| | - Elizete Maria Rita Pereira
- Graduate Program in Health Sciences, Institute of Education and
Research, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brazil
| | | | - Luciene Bruno Vieira
- Department of Pharmacology, Institute of Biological Sciences (ICB),
Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Alessandra Hubner de Souza
- Graduate Program in Health Sciences, Institute of Education and
Research, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brazil
| | - Flávia Karine Rigo
- Graduate Program in Health Sciences, University of the Extreme South
of Santa Catarina (UNESC), Criciúma, SC, Brazil
| | - Hèlia Tenza Ferrer
- Center of Technology in Molecular Medicine, School of Medicine,
Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
| | - Célio José de Castro
- Graduate Program in Health Sciences, Institute of Education and
Research, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brazil
| | - Juliano Ferreira
- Department of Pharmacology, Federal University of Santa Catarina,
Florianópolis, SC, Brazil
| | - Marcus Vinicius Gomez
- Graduate Program in Health Sciences, Institute of Education and
Research, Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brazil
- Center of Technology in Molecular Medicine, School of Medicine,
Federal University of Minas Gerais (UFMG), Belo Horizonte, MG, Brazil
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8
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Paul AK, Smith CM, Rahmatullah M, Nissapatorn V, Wilairatana P, Spetea M, Gueven N, Dietis N. Opioid Analgesia and Opioid-Induced Adverse Effects: A Review. Pharmaceuticals (Basel) 2021; 14:1091. [PMID: 34832873 PMCID: PMC8620360 DOI: 10.3390/ph14111091] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 01/08/2023] Open
Abstract
Opioids are widely used as therapeutic agents against moderate to severe acute and chronic pain. Still, these classes of analgesic drugs have many potential limitations as they induce analgesic tolerance, addiction and numerous behavioural adverse effects that often result in patient non-compliance. As opium and opioids have been traditionally used as painkillers, the exact mechanisms of their adverse reactions over repeated use are multifactorial and not fully understood. Older adults suffer from cancer and non-cancer chronic pain more than younger adults, due to the physiological changes related to ageing and their reduced metabolic capabilities and thus show an increased number of adverse reactions to opioid drugs. All clinically used opioids are μ-opioid receptor agonists, and the major adverse effects are directly or potentially connected to this receptor. Multifunctional opioid ligands or peripherally restricted opioids may elicit fewer adverse effects, as shown in preclinical studies, but these results need reproducibility from further extensive clinical trials. The current review aims to overview various mechanisms involved in the adverse effects induced by opioids, to provide a better understanding of the underlying pathophysiology and, ultimately, to help develop an effective therapeutic strategy to better manage pain.
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Affiliation(s)
- Alok K. Paul
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia;
| | - Craig M. Smith
- School of Medicine, Institute for Mental and Physical Health and Clinical Translation, Deakin University, Geelong, VIC 3216, Australia;
| | - Mohammed Rahmatullah
- Department of Biotechnology & Genetic Engineering, University of Development Alternative, Dhanmondi, Dhaka 1207, Bangladesh;
| | - Veeranoot Nissapatorn
- School of Allied Health Sciences, World Union for Herbal Drug Discovery (WUHeDD) and Research Excellence Center for Innovation and Health Products (RECIHP), Walailak University, Nakhon Si Thammarat 80160, Thailand;
| | - Polrat Wilairatana
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok 10400, Thailand
| | - Mariana Spetea
- Department of Pharmaceutical Chemistry, Institute of Pharmacy and Center for Molecular Biosciences (CMBI), University of Innsbruck, Innrain 80–82, 6020 Innsbruck, Austria;
| | - Nuri Gueven
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS 7001, Australia;
| | - Nikolas Dietis
- Medical School, University of Cyprus, Nicosia 1678, Cyprus;
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9
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Sapio MR, Vazquez FA, Loydpierson AJ, Maric D, Kim JJ, LaPaglia DM, Puhl HL, Lu VB, Ikeda SR, Mannes AJ, Iadarola MJ. Comparative Analysis of Dorsal Root, Nodose and Sympathetic Ganglia for the Development of New Analgesics. Front Neurosci 2021; 14:615362. [PMID: 33424545 PMCID: PMC7793666 DOI: 10.3389/fnins.2020.615362] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/25/2020] [Indexed: 12/18/2022] Open
Abstract
Interoceptive and exteroceptive signals, and the corresponding coordinated control of internal organs and sensory functions, including pain, are received and orchestrated by multiple neurons within the peripheral, central and autonomic nervous systems. A central aim of the present report is to obtain a molecularly informed basis for analgesic drug development aimed at peripheral rather than central targets. We compare three key peripheral ganglia: nodose, sympathetic (superior cervical), and dorsal root ganglia in the rat, and focus on their molecular composition using next-gen RNA-Seq, as well as their neuroanatomy using immunocytochemistry and in situ hybridization. We obtained quantitative and anatomical assessments of transmitters, receptors, enzymes and signaling pathways mediating ganglion-specific functions. Distinct ganglionic patterns of expression were observed spanning ion channels, neurotransmitters, neuropeptides, G-protein coupled receptors (GPCRs), transporters, and biosynthetic enzymes. The relationship between ganglionic transcript levels and the corresponding protein was examined using immunohistochemistry for select, highly expressed, ganglion-specific genes. Transcriptomic analyses of spinal dorsal horn and intermediolateral cell column (IML), which form the termination of primary afferent neurons and the origin of preganglionic innervation to the SCG, respectively, disclosed pre- and post-ganglionic molecular-level circuits. These multimodal investigations provide insight into autonomic regulation, nodose transcripts related to pain and satiety, and DRG-spinal cord and IML-SCG communication. Multiple neurobiological and pharmacological contexts can be addressed, such as discriminating drug targets and predicting potential side effects, in analgesic drug development efforts directed at the peripheral nervous system.
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Affiliation(s)
- Matthew R Sapio
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Fernando A Vazquez
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Amelia J Loydpierson
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Dragan Maric
- Flow and Imaging Cytometry Core Facility, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, United States
| | - Jenny J Kim
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Danielle M LaPaglia
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Henry L Puhl
- Section on Neurotransmitter Signaling, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, United States
| | - Van B Lu
- Section on Neurotransmitter Signaling, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, United States
| | - Stephen R Ikeda
- Section on Neurotransmitter Signaling, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, United States
| | - Andrew J Mannes
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
| | - Michael J Iadarola
- Anesthesia Section, Department of Perioperative Medicine, National Institutes of Health Clinical Center, Bethesda, MD, United States
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10
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Burdge G, Leach H, Walsh K. Ziconotide-induced psychosis: A case report and literature review. Ment Health Clin 2018; 8:242-246. [PMID: 30206508 PMCID: PMC6125118 DOI: 10.9740/mhc.2018.09.242] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Ziconotide is an intrathecally administered medication indicated for the treatment of severe chronic pain in patients who are intolerant of or refractory to other treatment options. A black box warning is included in the packaging and states ziconotide is contraindicated in patients with a preexisting history of psychosis. Patients taking ziconotide should be monitored for evidence of cognitive impairment, hallucinations, or changes in mood, and ziconotide should be discontinued if neurological or psychiatric signs and symptoms appear. We present a case of a 49-year-old white male with no previous neuropsychiatric history who received ziconotide for several years before he developed command auditory hallucinations within 24 hours of a dose increase. Upon admission to the emergency room, the patient's pain management physician was contacted and the ziconotide dose was decreased and eventually discontinued. Because of a continuation of symptoms, the patient was transferred from the emergency room to an acute care psychiatric hospital where he was started on risperidone 1 mg orally at bedtime. At discharge, the patient was noted to be in good behavioral control without any hallucinations. The patient was encouraged to follow up with his pain management physician to determine if ziconotide should be reconsidered.
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Affiliation(s)
- Gary Burdge
- (Corresponding author) PGY1 Pharmacy Resident, RWJ Barnabas Health Behavioral Health Center, Toms River, New Jersey,
| | - Henry Leach
- Clinical Coordinator, RWJ Barnabas Health Behavioral Health Center, Toms River, New Jersey
| | - Kim Walsh
- Director of Pharmacy, RWJ Barnabas Health Behavioral Health Center, Toms River, New Jersey
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11
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Pharmacology of Intrathecal Therapy. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00066-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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12
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Brookes ME, Eldabe S, Batterham A. Ziconotide Monotherapy: A Systematic Review of Randomised Controlled Trials. Curr Neuropharmacol 2017; 15:217-231. [PMID: 26861472 PMCID: PMC5412704 DOI: 10.2174/1570159x14666160210142056] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 12/31/2015] [Accepted: 01/26/2016] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Chronic neuropathic pain is difficult to treat and is often refractory to most modalities of treatment. Ziconotide is a novel, potent, non-opioid, calcium channel blocking agent which has been shown in clinical trials to be effective in treating chronic neuropathic pain. METHODS EMBASE, MEDLINE, CINAHL Plus and Web of Science electronic databases were searched for English language studies. Reference sections of articles were examined for further papers and the manufacturer of ziconotide was contacted for further unpublished data. Three randomised controlled trials in ziconotide monotherapy were included and subjected to a random effects meta-analysis. RESULTS All three studies used the similar main outcome measure (visual analogue scale of pain intensity; VASPI) and were therefore comparable. A Jadad score was performed for each paper. Frequent serious adverse events (SAEs) were observed which resulted in two of the studies revising the protocol. The metaanalysis revealed a pooled odds ratio (responders on ziconotide vs. placebo) of 2.77 (95% CI, 1.37 to 5.59). DISCUSSION The results suggest that ziconotide is beneficial for pain reduction in chronic neuropathic pain. However, there remain some methodological issues that may call into question the validity of the results. It is evident that more work needs to be conducted to further validate the efficacy of ziconotide and to discover new areas of use.
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Affiliation(s)
- Morag E. Brookes
- Department of Anaesthesia and Pain Management, The James Cook
University Hospital, Middlesbrough, TS4 3BW, UK
- Department of Anaesthesia and Pain Management, The James Cook
University Hospital, Middlesbrough, TS4 3BW, UK
| | - Sam Eldabe
- Department of Anaesthesia and Pain Management, The James Cook
University Hospital, Middlesbrough, TS4 3BW, UK
| | - Alan Batterham
- Teesside University, Borough Road, Middlesbrough, TS1 3BA
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13
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Pope JE, Deer TR, Bruel BM, Falowski S. Clinical Uses of Intrathecal Therapy and Its Placement in the Pain Care Algorithm. Pain Pract 2016; 16:1092-1106. [PMID: 26914961 DOI: 10.1111/papr.12438] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 11/17/2015] [Accepted: 12/02/2015] [Indexed: 11/29/2022]
Abstract
Intrathecal drug delivery is an effective treatment option for patients with severe chronic pain who have not obtained adequate analgesia from more conservative therapies (eg, physical therapy, systemic opioids, nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsants). This review focuses on, but is not limited to, the 2 agents currently approved by the U.S. Food and Drug Administration for intrathecal analgesia: preservative-free morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker). We describe the appropriate use of intrathecal therapy in the management of severe chronic pain, based on current best practices. Topics addressed here include patient selection, trialing, dosing and titration, adverse event profiles, long-term management, intrathecal therapy for cancer-related pain, and the placement of intrathecal therapy in the pain care algorithm. In appropriately selected patients with chronic pain, intrathecal therapy can provide substantial pain relief with improved functioning and quality of life. Successful long-term management requires ongoing patient monitoring for changes in efficacy and the occurrence of adverse events, with subsequent changes in intrathecal dosing and titration, the addition of adjuvant intrathecal agents, and the use of concomitant oral medications to address side effects, as needed. Based on an infrequent but clinically concerning risk of overdose, granuloma, and other opioid-induced complications, nonopioid therapy with ziconotide may be preferred as a first-line intrathecal therapy in patients without a history of psychosis or allergy.
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Affiliation(s)
- Jason E Pope
- Summit Pain Alliance, Santa Rosa, California, U.S.A
| | - Timothy R Deer
- Center for Pain Relief, Charleston, West Virginia, U.S.A
| | - Brian M Bruel
- University of Texas, M.D. Anderson Cancer Center, Houston, Texas, U.S.A
| | - Steven Falowski
- St. Luke's Neurosurgical Associates, St. Luke's University Health Network, Bethlehem, Pennsylvania, U.S.A
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14
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Vayne-Bossert P, Afsharimani B, Good P, Gray P, Hardy J. Interventional options for the management of refractory cancer pain--what is the evidence? Support Care Cancer 2015; 24:1429-38. [PMID: 26660344 DOI: 10.1007/s00520-015-3047-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/29/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Pain is the most common symptom in cancer patients. Standard pain treatment according to the WHO three-step analgesic ladder provides effective pain management in approximately 70-90% of cancer patients. Refractory pain is defined as not responding to "standard" treatments. Interventional analgesic techniques can be used in an attempt to control refractory pain in patients in whom conventional analgesic strategies fail to provide effective pain relief or are intolerable due to severe adverse effects. This systematic review aims to provide the latest evidence on interventional refractory pain management in cancer patients. METHODS Systematic literature search in Cochrane, EMBASE and PubMed including reviews and randomised controlled trials (RCTs) and non-randomised controlled trials in the absence of reviews. RESULTS Neuraxial analgesia may play a role in refractory cancer pain management. Paravertebral blocks decrease the incidence of persistent post-surgical pain after breast cancer. Coeliac plexus blocks improve pain scores in refractory pancreatic cancer pain for up to 4 weeks after the intervention with fewer burdensome side effects as compared to opioids. Cordotomy has mainly been studied in mesothelioma, and the case series suggest possible benefit for pain at the expense of a relatively high risk of side effects. CONCLUSIONS Overall, very few RCTs have been conducted on interventional pain techniques. In reality, it is very difficult to undertake large controlled trials for a number of reasons. Therefore, today's best evidence for practice may be from large case series of comparable patients with careful response and toxicity evaluation and follow-up.
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Affiliation(s)
- Petra Vayne-Bossert
- Readaptation and Palliative Care, University Hospital of Geneva, Geneva, Switzerland.,Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia
| | - Banafsheh Afsharimani
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia
| | - Phillip Good
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia.,Palliative Care Services, St Vincent's Private Hospital Brisbane, Kangaroo Point, Australia
| | - Paul Gray
- School of Medicine, University of Queensland, St Lucia, Australia.,Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Australia
| | - Janet Hardy
- Palliative and Supportive Care, Mater Health Services Brisbane, Raymond Terrace, South Brisbane, 4101, QLD, Australia. .,School of Medicine, University of Queensland, St Lucia, Australia.
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15
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de la Calle Gil AB, Peña Vergara I, Cormane Bornacelly MA, Pajuelo Gallego A. Intrathecal Ziconotide and Morphine for Pain Relief: A Case Series of Eight Patients with Refractory Cancer Pain, Including Five Cases of Neuropathic Pain. Neurol Ther 2015; 4:159-68. [PMID: 26563119 PMCID: PMC4685866 DOI: 10.1007/s40120-015-0035-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Indexed: 11/29/2022] Open
Abstract
Introduction Studies have shown that, at low doses and with careful titration, combination therapy with intrathecal ziconotide and morphine results in rapid control of opioid-refractory cancer pain. However, there is a lack of published data regarding the efficacy and safety of intrathecal ziconotide specifically for the treatment of neuropathic cancer pain. Case series Case reports of ziconotide intrathecal infusion in eight patients (age 45–71 years; 75% male) with chronic, uncontrolled cancer pain during therapy with intrathecal morphine plus bupivacaine were reviewed. Neuropathic pain was confirmed in five patients. Treatment was initiated with adjunctive ziconotide when pain ≥5 on a visual analog scale persisted in spite of 3 successive 20% dose increases of intrathecal morphine. Ziconotide was initiated at 0.5–1.0 µg/day, with mean increases of 0.5 µg every 4–7 days if required (maximum dose 10 µg/day; mean dose 4.9 µg/day). Pain intensity was reduced in all patients after 3–5 days. Of the eight patients, three died for reasons unrelated to ziconotide, three discontinued treatment due to adverse effects (predominantly psychoneurological disorders), and one patient is still receiving treatment. One patient discontinued ziconotide due to confusion and delirium. Due to continued lack of pain control with intrathecal morphine, intrathecal fentanyl was initiated; however, effective pain relief was not achieved with 1500 µg/day. Ziconotide was restarted and the patient then achieved pain control. Conclusion On the basis of our clinical experience, we recommend adding ziconotide to intrathecal opioid-based therapy in cancer patients with neuropathic pain inadequately controlled by intrathecal morphine alone. Funding Eisai, Spain. Electronic supplementary material The online version of this article (doi:10.1007/s40120-015-0035-z) contains supplementary material, which is available to authorized users.
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16
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Hayek SM, Hanes MC, Wang C, Veizi IE. Ziconotide Combination Intrathecal Therapy for Noncancer Pain Is Limited Secondary to Delayed Adverse Effects: A Case Series With a 24-Month Follow-Up. Neuromodulation 2015; 18:397-403. [PMID: 25655991 DOI: 10.1111/ner.12270] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/23/2014] [Accepted: 12/04/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The efficacy and safety of ziconotide as a single agent has been evaluated in few short-term clinical trials and open-label studies. Ziconotide use is challenging given its adverse effect (AE) profile. The objective of this study is to describe the long-term efficacy and AEs of ziconotide used as an adjunct to other intrathecal (IT) agents in chronic noncancer pain patients. MATERIALS AND METHODS A case series of chronic noncancer pain patients who had suboptimal pain control from IT therapy. Ziconotide was introduced in the IT infusion mixture after a successful ziconotide trial. Pain scores, IT doses, as well as AEs were recorded and analyzed from trial to initial ziconotide infusion and up to 24 months. RESULTS Fifteen patients underwent ziconotide trials. Four subjects failed the trial, and 11 proceeded to continuous ziconotide treatment. Seven out of 11 patients experienced AEs resulting in ziconotide discontinuation. Two of the seven subjects who required discontinuation of ziconotide had improved pain. Four subjects were able to continue IT ziconotide through 24 months. CONCLUSIONS A high incidence of AEs limits the usefulness of IT ziconotide as adjunct therapy. Our results are limited by the size of our patient population; however, they represent a long follow-up period, which is limited in most current publications on this IT peptide. While ziconotide is a needed IT agent, more studies are necessary to better understand the factors that would improve the treatment to trial ratio as well as the long-term efficacy of IT ziconotide treatment.
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Affiliation(s)
- Salim M Hayek
- Department of Anesthesiology, Division of Pain Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Michael C Hanes
- Department of Anesthesiology, Division of Pain Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Connie Wang
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - I Elias Veizi
- Department of Anesthesiology, Division of Pain Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA.,Pain Medicine & Spine Care, Louis Stokes Veterans Administration Medical Center, Cleveland, OH, USA
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18
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Ren Z, Wang L, Qin M, You Y, Pan W, Zhou L, Sun D, Xu A. Pharmacological characterization of conotoxin lt14a as a potent non-addictive analgesic. Toxicon 2015; 96:57-67. [PMID: 25617597 DOI: 10.1016/j.toxicon.2015.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 01/19/2015] [Accepted: 01/21/2015] [Indexed: 01/18/2023]
Abstract
Conotoxin lt14a is a small peptide consisting of 13 amino acids. It was originally identified from the cDNA of Conus litteratus in the South China Sea. Previous reports showed lt14a exhibited antinociceptive activity using a hot plate-induced pain mouse model and acted as an antagonist of neuronal nicotinic acetylcholine receptors. We confirmed that conotoxin lt14a administration resulted in antinociception activity using a mouse inflammatory pain model and a rat model of mechanically-induced pain. The mRNA expression of c-fos and NOS in the spinal cord of rats was suppressed by lt14a. Labeling of lt14a with an Alexa Fluor 488 ester showed that lt14a was bound to the surface of PC12 cells and that this binding was inhibited by pre-application of the nicotinic acetylcholine receptor (nAChR) antagonist tubocurarine chloride (TUB) and the nAChR blocker hexamethonium bromide (HB). These data confirm previous reports that showed lt14a binds to the surface of PC12 cells via nAChRs with patch clamp whole-cell recordings. Additional results showed that lt14a suppressed extracellular signal-regulated kinase (ERK1/2) phosphorylation in PC12 cells activated by Ach. Our results showed that lt14a did not induce drug dependence but rather suppressed morphine withdrawal symptoms. Our work suggests that lt14a is a novel antinociceptive agent that targets the nAChR receptor without inducing drug dependence.
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Affiliation(s)
- Zhenghua Ren
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China
| | - Lei Wang
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China.
| | - Mengying Qin
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China
| | - Yuwen You
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China
| | - Wuguang Pan
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China
| | - Liang Zhou
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China
| | - Dandan Sun
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China
| | - Anlong Xu
- State Key Laboratory of Biocontrol, Guangdong Province Key Laboratory of Pharmaceutical Functional Genes, National Engineering Research Center of South China Sea Marine Biotechnology, Department of Biochemistry, College of Life Sciences, Sun Yat-sen University, Guangzhou, 510275, People's Republic of China; Beijing University of Chinese Medicine, 11 Bei San Huan Dong Road, Beijing, 100029, People's Republic of China.
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Gulati A, Loh J, Puttanniah V, Malhotra V. The use of combined spinal-epidural technique to compare intrathecal ziconotide and epidural opioids for trialing intrathecal drug delivery. Pain Manag 2014; 3:123-8. [PMID: 24645996 DOI: 10.2217/pmt.13.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Choosing the initial medications for intrathecal delivery is often confusing and not standardized. We describe a novel way for using a combined spinal-epidural technique to compare two first-line medications for intrathecal delivery; ziconotide and morphine (or hydromorphone). Five patients with intractable chronic or cancer pain were elected to have an intrathecal drug delivery system implanted for pain management. Each patient was given a 3-day inpatient trial with the combined spinal-epidural technique. The Visual Analog Scale, Numerical Rating Scale, short-term McGill questionnaire and opioid consumption were monitored daily. The results were used to develop a paradigm to describe how ziconotide can be used in practice.
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Affiliation(s)
- Amitabh Gulati
- Department of Anesthesiology & Critical Care, Memorial Sloan-Kettering Cancer Center M308, New York, NY 10065, USA
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Abstract
Cancer pain is a serious health problem, and imposes a great burden on the lives of patients and their families. Pain can be associated with delay in treatment, denial of treatment, or failure of treatment. If the pain is not treated properly it may impair the quality of life. Neuropathic cancer pain (NCP) is one of the most complex phenomena among cancer pain syndromes. NCP may result from direct damage to nerves due to acute diagnostic/therapeutic interventions. Chronic NCP is the result of treatment complications or malignancy itself. Although the reason for pain is different in NCP and noncancer neuropathic pain, the pathophysiologic mechanisms are similar. Data regarding neuropathic pain are primarily obtained from neuropathic pain studies. Evidence pertaining to NCP is limited. NCP due to chemotherapeutic toxicity is a major problem for physicians. In the past two decades, there have been efforts to standardize NCP treatment in order to provide better medical service. Opioids are the mainstay of cancer pain treatment; however, a new group of therapeutics called coanalgesic drugs has been introduced to pain treatment. These coanalgesics include gabapentinoids (gabapentin, pregabalin), antidepressants (tricyclic antidepressants, duloxetine, and venlafaxine), corticosteroids, bisphosphonates, N-methyl-D-aspartate antagonists, and cannabinoids. Pain can be encountered throughout every step of cancer treatment, and thus all practicing oncologists must be capable of assessing pain, know the possible underlying pathophysiology, and manage it appropriately. The purpose of this review is to discuss neuropathic pain and NCP in detail, the relevance of this topic, clinical features, possible pathology, and treatments of NCP.
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Affiliation(s)
- Ece Esin
- Medical Oncology Department, Hacettepe University Cancer Institute, Ankara, Turkey
| | - Suayib Yalcin
- Medical Oncology Department, Hacettepe University Cancer Institute, Ankara, Turkey
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Lee MS. Recent Progress in the Discovery and Development of N-Type Calcium Channel Modulators for the Treatment of Pain. PROGRESS IN MEDICINAL CHEMISTRY 2014; 53:147-86. [DOI: 10.1016/b978-0-444-63380-4.00004-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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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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23
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Kumar K, Rizvi S, Bishop S, Tang W. Cost Impact of Intrathecal Polyanalgesia. PAIN MEDICINE 2013; 14:1569-84. [DOI: 10.1111/pme.12204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Levy RM. The failed and future promise of intraspinal drug administration for neurologic disorders. Neuromodulation 2012; 15:165-70. [PMID: 22672049 DOI: 10.1111/j.1525-1403.2012.00468.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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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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Alicino I, Giglio M, Manca F, Bruno F, Puntillo F. Intrathecal combination of ziconotide and morphine for refractory cancer pain: A rapidly acting and effective choice. Pain 2012; 153:245-249. [DOI: 10.1016/j.pain.2011.10.002] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Revised: 07/09/2011] [Accepted: 10/03/2011] [Indexed: 11/17/2022]
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Jones RCW, Moeller-Bertram T, Wallace MS. Safety and efficacy of intrathecal drug delivery for pain. Pain Manag 2012; 2:55-61. [DOI: 10.2217/pmt.11.76] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The practice of delivering analgesic drugs into the intrathecal space has evolved over the past several decades from a ‘last-ditch’ therapy for intractable pain in patients with terminal cancer to a more widely applied strategy for treating patients with chronic nonmalignant pain as well. This review discusses the available safety and efficacy data of intrathecal drug delivery with a focus on device- and user-related safety issues.
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Affiliation(s)
- R Carter W Jones
- Department of Anesthesiology, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7651, USA
- VA San Diego Healthcare System, San Diego, CA, USA
| | - Tobias Moeller-Bertram
- Department of Anesthesiology, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7651, USA
- VA San Diego Healthcare System, San Diego, CA, USA
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Pexton T, Moeller-Bertram T, Schilling JM, Wallace MS. Targeting voltage-gated calcium channels for the treatment of neuropathic pain: a review of drug development. Expert Opin Investig Drugs 2011; 20:1277-84. [DOI: 10.1517/13543784.2011.600686] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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30
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Kolosov A, Aurini L, Williams ED, Cooke I, Goodchild CS. Intravenous Injection of Leconotide, an Omega Conotoxin: Synergistic Antihyperalgesic Effects with Morphine in a Rat Model of Bone Cancer Pain. PAIN MEDICINE 2011; 12:923-41. [DOI: 10.1111/j.1526-4637.2011.01118.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Antinociceptive effect of Brazilian armed spider venom toxin Tx3-3 in animal models of neuropathic pain. Pain 2011; 152:2224-2232. [PMID: 21570770 DOI: 10.1016/j.pain.2011.04.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 02/04/2011] [Accepted: 04/08/2011] [Indexed: 11/23/2022]
Abstract
Venoms peptides have produced exceptional sources for drug development to treat pain. In this study we examined the antinociceptive and side effects of Tx3-3, a peptide toxin isolated from Phoneutria nigriventer venom, which inhibits high-voltage-dependent calcium channels (VDCC), preferentially P/Q and R-type VDCC. We tested the effects of Tx3-3 in animal models of nociceptive (tail-flick test), neuropathic (partial sciatic nerve ligation and streptozotocin-induced diabetic neuropathy), and inflammatory (intraplantar complete Freund's adjuvant) pain. In the tail-flick test, both intrathecal (i.t.) and intracerebroventricular (i.c.v.) injection of Tx3-3 in mice caused a short-lasting effect (ED(50) and 95% confidence intervals of 8.8 [4.1-18.8] and 3.7 [1.6-8.4] pmol/site for i.t. and i.c.v. injection, respectively), without impairing motor functions, at least at doses 10-30 times higher than the effective dose. By comparison, ω-conotoxin MVIIC, a P/Q and N-type VDCC blocker derived from Conus magus venom, caused significant motor impairment at doses close to efficacious dose in tail flick test. Tx3-3 showed a long-lasting antinociceptive effect in neuropathic pain models. Intrathecal injection of Tx3-3 (30 pmol/site) decreased both mechanical allodynia produced by sciatic nerve injury in mice and streptozotocin-induced allodynia in mice and rats. On the other hand, i.t. injection of Tx3-3 did not alter inflammatory pain. Taken together, our data show that Tx3-3 shows prevalent antinociceptive effects in the neuropathic pain models and does not cause adverse motor effects at antinociceptive efficacious doses, suggesting that this peptide toxin holds promise as a novel therapeutic agent for the control of neuropathic pain. The Brazilian armed spider Tx3-3, a new P/Q and R-type calcium channel blocker, effectively alleviates allodynia in animal neuropathic pain models.
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Lawson EF, Wallace MS. Current developments in intraspinal agents for cancer and noncancer pain. Curr Pain Headache Rep 2010; 14:8-16. [PMID: 20425209 PMCID: PMC2826634 DOI: 10.1007/s11916-009-0092-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Since the late 1980s, intrathecal (IT) analgesic therapy has improved, and implantable IT drug delivery devices have become increasingly sophisticated. Physicians and patients now have myriad more options for agents and their combination, as well as for refining their delivery. As recently as 2007, The Polyanalgesic Consensus Conference of expert panelists updated its algorithm for drug selection in IT polyanalgesia. We review this algorithm and the emerging therapy included. This article provides an update on newly approved as well as emerging IT agents and the advances in technology for their delivery.
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Affiliation(s)
- Erin F Lawson
- Division of Pain Medicine, Department of Anesthesiology, University of California, San Diego, La Jolla, CA 92037, USA.
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Yan LD, Liu YL, Zhang L, Dong HJ, Zhou PL, Su RB, Gong ZH, Huang PT. Spinal antinociception of synthetic omega-conotoxin SO-3, a selective N-type neuronal voltage-sensitive calcium channel blocker, and its effects on morphine analgesia in chemical stimulus tests in rodent. Eur J Pharmacol 2010; 636:73-81. [DOI: 10.1016/j.ejphar.2010.03.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 02/25/2010] [Accepted: 03/12/2010] [Indexed: 11/17/2022]
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Abstract
Pharmacological management of severe chronic pain is difficult to achieve with currently available analgesic drugs, and remains a large unmet therapeutic need. The synthetic peptide ziconotide has been approved by the US Food and Drug Administration and the European Medicines Agency for intrathecal treatment of patients with severe chronic pain that is refractory to other treatment modalities. Ziconotide is the first member in the new drug class of selective N-type voltage-sensitive calcium-channel blockers. The ziconotide-induced blockade of N-type calcium channels in the spinal cord inhibits release of pain-relevant neurotransmitters from central terminals of primary afferent neurons. By this mechanism, ziconotide can effectively reduce pain. However, ziconotide has a narrow therapeutic window because of substantial CNS side-effects, and thus treatment with ziconotide is appropriate for only a small subset of patients with severe chronic pain. We provide an overview of the benefits and limitations of intrathecal ziconotide treatment and review potential future developments in this new drug class.
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Affiliation(s)
- Achim Schmidtko
- Pharmazentrum Frankfurt/ZAFES, Institut für Klinische Pharmakologie, Goethe-Universität, Frankfurt am Main, Germany
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Kolosov A, Goodchild CS, Cooke I. CNSB004 (Leconotide) Causes Antihyperalgesia Without Side Effects When Given Intravenously: A Comparison with Ziconotide in a Rat Model of Diabetic Neuropathic Pain. PAIN MEDICINE 2010; 11:262-73. [DOI: 10.1111/j.1526-4637.2009.00741.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kress HG, Simpson KH, Marchettini P, Ver Donck A, Varrassi G. Intrathecal therapy: what has changed with the introduction of ziconotide. Pain Pract 2009; 9:338-47. [PMID: 19740270 DOI: 10.1111/j.1533-2500.2009.00308.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Administering drugs into the intrathecal space is becoming more popular in the treatment of patients with intractable pain or intolerable side effects of systemic analgesic treatments. Although morphine and ziconotide are the only intrathecal analgesics currently approved by regulatory authorities in the U.S. (Food and Drug Administration) and Europe (national-level approval by individual countries for morphine and European Agency for the Evaluation of Medicinal Products approval for ziconotide), a wide variety of opioid and non-opioid drugs are being used in this way. There is no official guidance concerning the selection of these drugs or their use in combinations and a paucity of efficacy and safety data from randomized controlled trials. The polyanalgesic initiative aims to summarize the current knowledge and to facilitate rational choices of intrathecal drug and drug combinations for the management of chronic pain. The most recent polyanalgesic consensus recommendations were published in 2007. In this review, we shall examine these recommendations, which are tailored toward those practicing intrathecal analgesia in the U.S., and discuss how they should be implemented in Europe, where the healthcare systems and regulations of the medical authorities are different.
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Affiliation(s)
- Hans G Kress
- Medical University of Vienna, A-1090 Vienna, Austria.
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Rauck RL, Wallace MS, Burton AW, Kapural L, North JM. Intrathecal ziconotide for neuropathic pain: a review. Pain Pract 2009; 9:327-37. [PMID: 19682321 DOI: 10.1111/j.1533-2500.2009.00303.x] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Neuropathic pain is a considerable burden that affects activities of daily living. The management of neuropathic pain can be challenging because of multiple etiologies and complex manifestations. Ziconotide is a nonopioid intrathecal (IT) analgesic option for patients with neuropathic pain refractory to conventional treatments. The objective of this article is to review the published literature on ziconotide for the treatment of neuropathic pain. Relevant publications were identified through searches of all years of 6 databases, which included PubMed, EMBASE, and CINAHL. Search terms used were ziconotide, SNX-111, MVIIA, Prialt, and neuropathic pain. Publications were included if ziconotide was intrathecally administered (either alone or in combination with other IT agents) to treat neuropathic pain of any etiology and if pain assessment was an outcome measure. Data extracted included study design, IT drug doses, pain outcome measures, and adverse events (AEs). Twenty-eight articles met the inclusion criteria: 5 were preclinical studies and 23 were clinical studies. In the preclinical studies, ziconotide demonstrated antiallodynic effects on neuropathic pain. Data from double-blind, placebo-controlled (DBPC) trials indicated that patients with neuropathic pain reported a mean percent improvement in pain score with ziconotide monotherapy that ranged from 15.7% to 31.6%. A low starting dose and slow titration of ziconotide resulted in an improved safety profile in the aforementioned trials. Common AEs associated with ziconotide include nausea and/or vomiting, dizziness, confusion, urinary retention, and somnolence. Evidence from DBPC trials, open-label studies, case series, and case studies suggests that ziconotide, as either monotherapy or in combination with other IT drugs, is a potential therapeutic option for patients with refractory neuropathic pain. Additional studies are needed to establish the long-term efficacy and safety of ziconotide for neuropathic pain.
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Affiliation(s)
- Richard L Rauck
- Wake Forest University Health Sciences, Winston-Salem, North Carolina 27103, USA.
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Smith HS, Deer TR. Safety and efficacy of intrathecal ziconotide in the management of severe chronic pain. Ther Clin Risk Manag 2009; 5:521-34. [PMID: 19707262 PMCID: PMC2710384 DOI: 10.2147/tcrm.s4438] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Ziconotide is a conopeptide intrathecal (IT) analgesic which is approved by the US Food and Drug Administration (FDA) for the management of severe chronic pain. It is a synthetic equivalent of a naturally occurring conopeptide found in the venom of the fish-eating marine cone snail and provides analgesia via binding to N-type voltage-sensitive calcium channels in the spinal cord. As ziconotide is a peptide, it is expected to be completely degraded by endopeptidases and exopeptidases (Phase I hydrolytic enzymes) widely located throughout the body, and not by other Phase I biotransformation processes (including the cytochrome P450 system) or by Phase II conjugation reactions. Thus, IT administration, low plasma ziconotide concentrations, and metabolism by ubiquitous peptidases make metabolic interactions of other drugs with ziconotide unlikely. Side effects of ziconotide which tend to occur more commonly at higher doses may include: nausea, vomiting, confusion, postural hypotension, abnormal gait, urinary retention, nystagmus/amblyopia, drowsiness/somnolence (reduced level of consciousness), dizziness or lightheadedness, weakness, visual problems (eg, double vision), elevation of serum creatine kinase, or vestibular side effects. Initially, when ziconotide was first administered to human subjects, titration schedules were overly aggressive and led to an abundance of adverse effects. Subsequently, clinicians have gained appreciation for ziconotide’s relatively narrow therapeutic window. With appropriate usage multiple studies have shown ziconotide to be a safe and effective intrathecal analgesic alone or in combination with other intrathecal analgesics.
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Affiliation(s)
- Howard S Smith
- Albany Medical College, Department of Anesthesiology, Albany, New York, USA
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Hama A, Sagen J. Antinociceptive effects of the marine snail peptides conantokin-G and conotoxin MVIIA alone and in combination in rat models of pain. Neuropharmacology 2008; 56:556-63. [PMID: 19010337 DOI: 10.1016/j.neuropharm.2008.10.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2008] [Revised: 10/18/2008] [Accepted: 10/21/2008] [Indexed: 12/25/2022]
Abstract
There are a number of neurologically active ion channel blocking peptides derived from cone snail venom, such as conantokin-G and omega-conotoxin MVIIA. Conantokin-G inhibits NMDA receptors containing the NR2B subunit whereas omega-conotoxin MVIIA blocks N-type Ca(2+) channels. Separately, these peptides induce antinociceptive effects in pre-clinical pain models following intrathecal injection. In the current study, the efficacies of these peptides were determined separately and in combination by intrathecal injection into rats with a spinal nerve ligation, in rats with a spinal cord compression injury and in the formalin test. Separately, both conantokin-G and omega-conotoxin MVIIA dose-dependently attenuated nociceptive responses in all of these models. However, at high antinociceptive doses for both formalin and nerve injury models, omega-conotoxin MVIIA evoked untoward side effects. Using isobolographic analysis, the combination of sub-antinociceptive doses of peptides demonstrated additive antinociception in rats with a nerve ligation and in the formalin test, without apparent adverse side effects. In a model of neuropathic spinal cord injury pain, which is clinically difficult to treat, the combination of conantokin-G and omega-conotoxin MVIIA resulted in robust synergistic antinociception. These data suggest that a combination of these peptides may be analgesic across diverse clinical pains with limited untoward side effects, and particularly potent for reducing spinal cord injury pain.
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Affiliation(s)
- Aldric Hama
- The Miami Project to Cure Paralysis, University of Miami, Miller School of Medicine, 1095 NW 14th Terrace, R-48, Miami, FL 33136, USA.
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Abstract
BACKGROUND Ziconotide is the only N-type calcium channel blocker approved by the US FDA for the treatment of chronic pain. The approved indication is for the management of severe chronic pain in patients for whom intrathecal therapy is warranted and who are intolerant of or refractory to other treatments such as systemic analgesics, adjunctive therapies or intrathecal morphine. OBJECTIVE The purpose of this article was to review the available safety, efficacy and dosing information for ziconotide. METHODS The sources searched for literature from 1980 to January 2008 included Pub Med, MEDLINE and PREMEDLINE using the words ziconotide, conotoxins and pain. RESULTS/CONCLUSION Ziconotide is administered intrathecally by infusion pump to block nociceptive signal transmission in the spinal cord. It is a synthetic neuroactive peptide equivalent to the omega conotoxin MVIIA, a constituent of the venom of the fish-hunting marine snail Conus magus. It is highly potent, has a steep dose-response curve, a slow onset of action and a narrow margin of safety and responses to dose adjustments are slow. Patients receiving ziconotide should be under the care of physicians experienced in the management of intrathecal infusion therapy for pain control and should have convenient access to medical facilities.
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Affiliation(s)
- Jason A Williams
- Texas Tech University Health Sciences Center, 3601 Fourth Street, MS 818, Lubbock, TX 79430, USA
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