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Deer TR, Hayek SM, Grider JS, Pope JE, Brogan SE, Gulati A, Hagedorn JM, Strand N, Hah J, Yaksh TL, Staats PS, Perruchoud C, Knezevic NN, Wallace MS, Pilitsis JG, Lamer TJ, Buchser E, Varshney V, Osborn J, Goel V, Simpson BA, Lopez JA, Dupoiron D, Saulino MF, McDowell GC, Piedimonte F, Levy RM. The Polyanalgesic Consensus Conference (PACC)®: Updates on Clinical Pharmacology and Comorbidity Management in Intrathecal Drug Delivery for Cancer Pain. Neuromodulation 2024:S1094-7159(24)00670-6. [PMID: 39297833 DOI: 10.1016/j.neurom.2024.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 07/23/2024] [Accepted: 08/13/2024] [Indexed: 09/29/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians based on expertise with international representation to establish evidence-based guidance on using intrathecal drug delivery in chronic pain treatment. This Polyanalgesic Consensus Conference (PACC)® project's scope is to provide evidence-based guidance for clinical pharmacology and best practices for intrathecal drug delivery for cancer pain. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches using Medline, EMBASE, Cochrane CENTRAL, BioMed Central, Web of Science, Google Scholar, PubMed, Current Contents Connect, Meeting Abstracts, and Scopus from 2017 (when the PACC last published guidelines) to the present. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations were based on the strength of evidence, and when evidence was scant, recommendations were based on expert consensus. RESULTS The PACC evaluated the published literature and established evidence- and consensus-based expert opinion recommendations to guide best practices in treating cancer pain. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The PACC recommends best practices regarding the use of intrathecal drug delivery in cancer pain, with an emphasis on managing the unique disease and patient characteristics encountered in oncology. These evidence- and consensus-based expert opinion recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | | | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jennifer Hah
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA
| | - Tony L Yaksh
- Anesthesiology and Pharmacology, University of California San Diego, San Diego, CA, USA
| | - Peter S Staats
- ElectroCore, Rockaway, NJ, USA; National Spine and Pain Centers, Rockville, MD, USA
| | | | - Nebojsa Nick Knezevic
- Department of Anesthesiology and Surgery at University of Illinois, Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Mark S Wallace
- Division of Pain Management, Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, University of Arizona, Tucson, AZ, USA
| | - Tim J Lamer
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric Buchser
- Department of Anaesthesia and Pain Management, Neuromodulation Centre, Morges, Switzerland
| | - Vishal Varshney
- Providence Health Care, University of British Columbia, British Columbia, Canada
| | - Jill Osborn
- Department of Anesthesiology, Providence Health Care, Vancouver, British Columbia, Canada
| | - Vasudha Goel
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Brian A Simpson
- Department of Neurosurgery, Cardiff and Vale University Health Board, Cardiff, UK
| | - Jose A Lopez
- Service of Neurosurgery and Pain Clinic, University Hospital "Puerta del Mar," Cadiz, Spain
| | - Denis Dupoiron
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de L'Ouset, Angers, France
| | | | | | - Fabian Piedimonte
- Fundaciόn CENIT, University of Buenos Aires, Buenos Aires, Argentina
| | - Robert M Levy
- International Neuromodulation Society and Director of Neurosurgical Services, Director of Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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Zhang A, Wang H, Li Q, Chen C. Double-catheter intrathecal targeted drug delivery systems for the treatment of neck and abdominal cancer pain. Asian J Surg 2024:S1015-9584(24)01688-9. [PMID: 39152063 DOI: 10.1016/j.asjsur.2024.07.317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 07/25/2024] [Indexed: 08/19/2024] Open
Affiliation(s)
- Aimin Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, China; Department of Anesthesiology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, 610041, China
| | - Huaiming Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, China; Department of Anesthesiology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, 610041, China
| | - Qin Li
- Department of Anesthesiology, Sichuan Clinical Research Center for Cancer, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, Affiliated Cancer Hospital of University of Electronic Science and Technology of China, Chengdu, 610041, China
| | - Chan Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China; The Research Units of West China (2018RU012)-Chinese Academy of Medical Sciences, West China Hospital, Sichuan University, China.
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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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Mallick-Searle T, Adler JA. Update on Treating Painful Diabetic Peripheral Neuropathy: A Review of Current US Guidelines with a Focus on the Most Recently Approved Management Options. J Pain Res 2024; 17:1005-1028. [PMID: 38505500 PMCID: PMC10949339 DOI: 10.2147/jpr.s442595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/26/2024] [Indexed: 03/21/2024] Open
Abstract
Painful diabetic peripheral neuropathy (DPN) is a highly prevalent and disabling complication of diabetes that is often misdiagnosed and undertreated. The management of painful DPN involves treating its underlying cause via lifestyle modifications and intensive glucose control, targeting its pathogenesis, and providing symptomatic pain relief, thereby improving patient function and health-related quality of life. Four pharmacologic options are currently approved by the US Food and Drug Administration (FDA) to treat painful DPN. These include three oral medications (duloxetine, pregabalin, and tapentadol extended release) and one topical agent (capsaicin 8% topical system). More recently, the FDA approved several spinal cord stimulation (SCS) devices to treat refractory painful DPN. Although not FDA-approved specifically to treat painful DPN, tricyclic antidepressants, serotonin/norepinephrine reuptake inhibitors, gabapentinoids, and sodium channel blockers are common first-line oral options in clinical practice. Other strategies may be used as part of individualized comprehensive pain management plans. This article provides an overview of the most recent US guidelines for managing painful DPN, with a focus on the two most recently approved treatment options (SCS and capsaicin 8% topical system), as well as evidence for using FDA-approved and guideline-supported drugs and devices. Also discussed are unmet needs for this patient population, and evidence for potential future treatments for painful DPN, including drugs with novel mechanisms of action, electrical stimulation devices, and nutraceuticals.
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Dupoiron D, Autier L, Lebrec N, Seegers V, Folliard C, Patsouris A, Campone M, Augereau P. Intrathecal Catheter for Chemotherapy in Leptomeningeal Carcinomatosis From HER2-Negative Metastatic Breast Cancer. J Breast Cancer 2023; 26:572-581. [PMID: 37704384 PMCID: PMC10761759 DOI: 10.4048/jbc.2023.26.e40] [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: 04/12/2023] [Revised: 07/19/2023] [Accepted: 08/20/2023] [Indexed: 09/15/2023] Open
Abstract
PURPOSE Most oncological treatments for leptomeningeal metastasis (LM) do not cross the blood-brain barrier (BBB). One therapeutic option is intrathecal (IT) chemotherapy. Both the brain-implanted Omaya reservoir and lumbar puncture (LP) are classic routes for IT chemotherapy delivery. An intrathecal catheter (IC) connected to a subcutaneous port is a recently developed option for the management of chemotherapy infusions. It is essential to evaluate the efficacy and safety of chemotherapy infusion using such device. METHODS We conducted a retrospective monocentric study within Institut de cancerologie de l'Ouest at Angers, including all patients with advanced breast cancer (aBC) with LM implanted with an IT device for IT chemotherapy between January 2013 and May 2020. The primary endpoint was overall survival (OS) and secondary endpoints included surgical feasibility, patient safety, and progression-free survival (PFS). The catheter was inserted through an LP, the tip was positioned at the right level and connected to a subcutaneous port implanted under the skin of the anterior thoracic wall. IT chemotherapy is painless and easy for qualified nurses to administer on an outpatient basis. RESULTS Thirty women underwent the implantation. No failures occurred during the procedure. A total of 77% of patients reported no complications after implantation. Only three complications required surgical treatment. The median number of IT chemotherapy courses per patient was 8 (range, 2-27). The tolerance profile for iterative IT chemotherapy was manageable in ambulatory care. With a median follow-up of 76.5 months (95% confidence interval [CI], 11.6-not available), the median OS was 158 days (95% CI, 87-235), and the median PFS was 116 days (95% CI, 58-174). CONCLUSION Infusing chemotherapy using an implanted catheter is an efficient option for managing IT chemotherapy with a good tolerance profile. Patient-reported outcomes for the evaluation of IT chemotherapy toxicity are currently being developed.
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Affiliation(s)
- Denis Dupoiron
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France.
| | - Lila Autier
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
| | - Nathalie Lebrec
- Department of Anesthesiology and Pain Medicine, Institut de Cancerologie de l'Ouest, Angers, France
| | - Valérie Seegers
- Department of Epidemiology and Biostatistics, Institut de Cancerologie de l'Ouest, Angers, France
| | - Caroline Folliard
- Department of Pharmacy, Institut de Cancerologie de l'Ouest, Angers, France
| | - Anne Patsouris
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
| | - Mario Campone
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
| | - Paule Augereau
- Department of Medical Oncology, Institut de Cancerologie de l'Ouest, Angers, France
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Hayek SM, Jones BA, Veizi E, Tran TQ, DeLozier SJ. Efficacy of Continuous Intrathecal Infusion Trialing with a Mixture of Fentanyl and Bupivacaine in Chronic Low Back Pain Patients. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:796-808. [PMID: 36515491 PMCID: PMC10321766 DOI: 10.1093/pm/pnac195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/11/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
Intrathecal trialing is used as a screening prognostic measure prior to intrathecal drug delivery system implant. The purpose of this study was to determine the efficacy of a continuous intrathecal infusion of an admixture of bupivacaine and fentanyl in patients with chronic low back pain. Patients with refractory chronic low back pain in the setting of previous lumbar spine surgery and/or chronic vertebral compression fracture(s) were enrolled in a randomized double blind cross-over study comparing saline infusion to infusion of a solution containing bupivacaine combined with low-dose fentanyl over a 14-18 hour period. The primary outcome measure was the change in pain intensity at the end of the screening trial. Patients who experienced significant pain reduction from either infusion relative to baseline pain were offered a permanent implant. In total, 36 patients were enrolled, with 31 patients trialed and 25 implanted. At the end of the screening trial, pain scores, at rest or with activity, decreased appreciably in both groups; however, significantly better improvements occurred in the fentanyl/bupivacaine group compared to saline both with activity and at rest (P = .016 and .006, respectively). Treatment order appeared to affect outcome with saline demonstrating a placebo response. At 12 months following implant, primary and secondary outcome measures continued to be significantly reduced from baseline. Continuous intrathecal delivery of a combination of zlow-dose fentanyl with bupivacaine is superior to saline in screening intrathecal trialing for back pain reduction. With longer term delivery, a sustained reduction of chronic low back pain was also observed.
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Affiliation(s)
- Salim M Hayek
- Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Anesthesiology/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Bradford A Jones
- Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Anesthesiology/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Pain Medicine Service, Northeast Ohio VA Health Care System (NEOHVAHCS), Cleveland, Ohio, USA
| | | | - Thang Q Tran
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sarah J DeLozier
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Van Zundert J, Rauck R. Intrathecal drug delivery in the management of chronic pain. Best Pract Res Clin Anaesthesiol 2023. [DOI: 10.1016/j.bpa.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
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Pope JE, Jassal N, Sayed D, Patterson D, McDowell G, Bux A, Lim P, Chang E, Nairizi A, Grodofsky S, Deer TR. Post-market, randomized, controlled, prospective study evaluating intrathecal pain medication versus conventional medical management in the non-cancer, refractory, chronic pain population (PROSPER). Expert Rev Med Devices 2022; 19:895-904. [DOI: 10.1080/17434440.2022.2152673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS
| | | | | | | | | | - Eric Chang
- Restore Orthopedics and Spine Center, Orange, CA
| | | | | | - Timothy R Deer
- The Spine and Nerve Centers of the Virginias, Charleston, WV
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Liu Y. Construction of talent training mechanism for innovation and entrepreneurship education in colleges and universities based on data fusion algorithm. Front Psychol 2022; 13:968023. [PMID: 36211907 PMCID: PMC9537772 DOI: 10.3389/fpsyg.2022.968023] [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] [Received: 06/13/2022] [Accepted: 09/01/2022] [Indexed: 11/23/2022] Open
Abstract
Nowadays, innovation and entrepreneurship courses occupy a very important place in universities and colleges and have also become an important teaching position in the process of building a new science. Colleges and universities actively respond to the challenge of “mass entrepreneurship and innovation” and define the goals and specifications of the talent training mechanism based on data fusion algorithms to cultivate as much high-quality applied talent as possible. In view of some shortcomings and problems in the current talent training mechanism in universities and colleges, this paper proposes a data fusion algorithm based on information fusion theory and proof theory. The aim is to verify the feasibility of establishing a talent training mechanism for innovation and entrepreneurship education in universities and colleges. And this paper analyzes and explores the data fusion algorithm and the elements of innovation and entrepreneurial talent training, and forms an operating mechanism for entrepreneurial talent training according to social needs. Among them, the efficiency of the data fusion algorithm used by the GM(1,1) model plays a significant role in the final result, and the minimum relative error value is 3.2%. Finally, it is concluded that we should focus on establishing a perfect talent training system for college students’ innovation and entrepreneurship education to improve students’ own comprehensive quality and various abilities, and to solve some social problems that are difficult to find employment in essence.
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Brogan SE, Sindt JE, Odell DW, Gulati A, Dupoiron D. Controversies in intrathecal drug delivery for cancer pain. Reg Anesth Pain Med 2022; 48:319-325. [PMID: 35977779 DOI: 10.1136/rapm-2022-103770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/31/2022] [Indexed: 11/03/2022]
Abstract
Pain and suffering related to cancer are challenging issues that continue to deserve consideration for treatment optimization. Advances in analgesic management and control of the underlying cancer have improved symptom management, yet many patients still suffer from uncontrolled pain. Intrathecal drug delivery has an established role in the management of refractory cancer pain, but there are significant knowledge gaps in our understanding and application of this therapy. This review addresses several areas of controversy, including the importance of intrathecal catheter tip location, the necessity of an intrathecal trial and the role of intrathecal ziconotide and local anesthetics. In each area, the evidence is discussed, with an emphasis on presenting practical clinical guidance and highlighting deficiencies in our knowledge that are worthy of future investigation.
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Affiliation(s)
- Shane E Brogan
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Jill E Sindt
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Daniel W Odell
- Department of Anesthesiology, University of Utah Health, Salt Lake City, Utah, USA
| | - Amitabh Gulati
- Department of Anesthesiology, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Denis Dupoiron
- Department of Anesthesia and Pain Medicine, Institut de Cancerologie de l'Ouest Site Paul Papin, Angers, France
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De Andres J, Hayek S, Perruchoud C, Lawrence MM, Reina MA, De Andres-Serrano C, Rubio-Haro R, Hunt M, Yaksh TL. Intrathecal Drug Delivery: Advances and Applications in the Management of Chronic Pain Patient. FRONTIERS IN PAIN RESEARCH 2022; 3:900566. [PMID: 35782225 PMCID: PMC9246706 DOI: 10.3389/fpain.2022.900566] [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] [Received: 03/20/2022] [Accepted: 05/02/2022] [Indexed: 11/19/2022] Open
Abstract
Advances in our understanding of the biology of spinal systems in organizing and defining the content of exteroceptive information upon which higher centers define the state of the organism and its role in the regulation of somatic and automatic output, defining the motor response of the organism, along with the unique biology and spatial organization of this space, have resulted in an increased focus on therapeutics targeted at this extracranial neuraxial space. Intrathecal (IT) drug delivery systems (IDDS) are well-established as an effective therapeutic approach to patients with chronic non-malignant or malignant pain and as a tool for management of patients with severe spasticity and to deliver therapeutics that address a myriad of spinal pathologies. The risk to benefit ratio of IDD makes it a useful interventional approach. While not without risks, this approach has a significant therapeutic safety margin when employed using drugs with a validated safety profile and by skilled practioners. The present review addresses current advances in our understanding of the biology and dynamics of the intrathecal space, therapeutic platforms, novel therapeutics, delivery technology, issues of safety and rational implementation of its therapy, with a particular emphasis upon the management of pain.
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Affiliation(s)
- Jose De Andres
- Surgical Specialties Department, Valencia University Medical School, Valencia, Spain
- Anesthesia Critical Care and Pain Management Department, Valencia, Spain
- *Correspondence: Jose De Andres
| | - Salim Hayek
- Department of Anesthesiology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Christophe Perruchoud
- Pain Center and Department of Anesthesia, La Tour Hospital, Geneva, Switzerland
- Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Melinda M. Lawrence
- Department of Anesthesiology, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Miguel Angel Reina
- Department of Anesthesiology, Montepríncipe University Hospital, Madrid, Spain
- CEU-San-Pablo University School of Medicine, Madrid, Spain
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL, United States
- Facultad de Ciencias de la Salud Universidad Francisco de Vitoria, Madrid, Spain
| | | | - Ruben Rubio-Haro
- Anesthesia and Pain Management Department, Provincial Hospital, Castellon, Spain
- Multidisciplinary Pain Clinic, Vithas Virgen del Consuelo Hospital, Valencia, Spain
| | - Mathew Hunt
- Department of Physiology, Karolinska Institute, Stockholm, Sweden
| | - Tony L. Yaksh
- Departments of Anesthesiology and Pharmacology, University of California, San Diego, San Diego, CA, United States
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Ericson T, Singla P, Kohan L. Intrathecal Pumps. Phys Med Rehabil Clin N Am 2022; 33:409-424. [DOI: 10.1016/j.pmr.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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The Role of Intrathecal Pumps in Nonmalignant Pain. Neurosurg Clin N Am 2022; 33:305-309. [DOI: 10.1016/j.nec.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Best Practices for Cervical Neurostimulation. Neuromodulation 2022; 25:35-52. [DOI: 10.1016/j.neurom.2021.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 08/31/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
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North American Neuromodulation Society Educational Curriculum for Intrathecal Drug Delivery Systems Implantation and Management. Neuromodulation 2022:S1094-7159(21)06945-2. [PMID: 35088723 DOI: 10.1016/j.neurom.2021.11.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/05/2021] [Accepted: 10/07/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Intrathecal drug delivery systems (IDDSs) are used for the treatment of pain and spasticity. A wide range of educational criteria exist for these devices. The North American Neuromodulation Society (NANS) Education Committee developed a comprehensive IDDS curriculum to function as a standard for physician graduate education and assessment through training and into practice. MATERIAL AND METHODS A multidisciplinary and diverse task force gathered by the NANS Education Committee met in person and virtually over several sessions and developed an IDDS curriculum modeling their previous work on spinal cord stimulation and following the Accreditation Council for Graduate Medical Education (ACGME) Milestones. There were iterative revisions and adaptations to the curriculum, and the final version was approved by the NANS Board of Directors. RESULTS The curriculum was developed with distinction between implanting physicians and managing physician and physicians who perform both tasks. There is a lateral temporal progression from early learner to practitioner, with advanced learner in the middle. In addition, there is a modular vertical organization that divides the curriculum into the six educational competencies outlined by the ACGME. CONCLUSION A comprehensive, modular, graduated, and segmented educational curriculum for IDDSs was developed by NANS. We propose the curriculum to be the standard for guidance and assessment of trainees and physicians pursuing training in implanting or managing IDDSs.
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Aman MM, Mahmoud A, Deer T, Sayed D, Hagedorn JM, Brogan SE, Singh V, Gulati A, Strand N, Weisbein J, Goree JH, Xing F, Valimahomed A, Pak DJ, El Helou A, Ghosh P, Shah K, Patel V, Escobar A, Schmidt K, Shah J, Varshney V, Rosenberg W, Narang S. The American Society of Pain and Neuroscience (ASPN) Best Practices and Guidelines for the Interventional Management of Cancer-Associated Pain. J Pain Res 2021; 14:2139-2164. [PMID: 34295184 PMCID: PMC8292624 DOI: 10.2147/jpr.s315585] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/18/2021] [Indexed: 12/17/2022] Open
Abstract
Moderate to severe pain occurs in many cancer patients during their clinical course and may stem from the primary pathology, metastasis, or as treatment side effects. Uncontrolled pain using conservative medical therapy can often lead to patient distress, loss of productivity, shorter life expectancy, longer hospital stays, and increase in healthcare utilization. Various publications shed light on strategies for conservative medical management for cancer pain and a few international publications have reviewed limited interventional data. Our multi-institutional working group was assembled to review and highlight the body of evidence that exists for opioid utilization for cancer pain, adjunct medication such as ketamine and methadone and interventional therapies. We discuss neurolysis via injections, neuromodulation including targeted drug delivery and spinal cord stimulation, vertebral tumor ablation and augmentation, radiotherapy and surgical techniques. In the United States, there is a significant variance in the interventional treatment of cancer pain based on fellowship training. As a first of its kind, this best practices and interventional guideline will offer evidenced-based recommendations for reducing pain and suffering associated with malignancy.
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Affiliation(s)
- Mansoor M Aman
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Ammar Mahmoud
- Department of Anesthesiology, Division of Pain Medicine, Northern Light Health Eastern Maine Medical Center, Bangor, ME, USA
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Dawood Sayed
- Department of Anesthesiology, Pain and Perioperative Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shane E Brogan
- Department of Anesthesiology, Division of Pain Medicine, University of Utah, Salt Lake City, UT, USA
| | - Vinita Singh
- Department of Anesthesiology, Division of Pain Medicine, Emory University, Atlanta, GA, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natalie Strand
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Jacqueline Weisbein
- Department of Anesthesiology, Chronic Pain Division, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Johnathan H Goree
- Interventional Pain Medicine, Napa Valley Orthopedic Medical Group, Napa, CA, USA
| | - Fangfang Xing
- Swedish Pain Services, Swedish Health Services, Seattle, WA, USA
| | - Ali Valimahomed
- Gramercy Pain Center, Holmdel, NJ, & Advanced Orthopedics Sports Medicine Institute, Freehold, NJ, USA
| | - Daniel J Pak
- Department of Anesthesiology, Division of Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medical College, New York, NY, USA
| | - Antonios El Helou
- Department of Neurosciences, Division of Neurosurgery, The Moncton Hospital, Moncton, NB. Assistant Professor, Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | | | - Krishna Shah
- Assistant Professor of Anesthesiology, Baylor St. Luke’s Medical Center, Baylor College of Medicine, Houston, TX, USA
| | - Vishal Patel
- Department of Anesthesiology, Division of Pain Medicine, Advocate Aurora Health, Oshkosh, WI, USA
| | - Alexander Escobar
- Department of Anesthesiology and Pain Medicine, University of Toledo Medical Center, Toledo, OH, USA
| | - Keith Schmidt
- AMITA Neurosciences Institute, Comprehensive Pain Management Program, St. Alexius Medical Center, Hoffman Estates, IL, USA
| | - Jay Shah
- SamWell Institute for Pain Management, Colonia, NJ, USA
| | - Vishal Varshney
- Department of Anesthesia, Providence Healthcare, Vancouver, BC, Canada & Department of Anesthesiology, Pharmacology, Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - William Rosenberg
- Center for the Relief of Pain, Midwest Neurosurgery Associates, Kansas City, Missouri, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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17
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Yang A, Nadav D, Legler A, Chen GH, Hingula L, Puttanniah V, Gulati A. An Interventional Pain Algorithm for the Treatment of Postmastectomy Pain Syndrome: A Single-Center Retrospective Review. PAIN MEDICINE 2021; 22:677-686. [PMID: 33155049 DOI: 10.1093/pm/pnaa343] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Breast cancer is the most common female malignancy worldwide. Breast surgery and adjuvant oncological therapies are often required to increase survival. Treatment-related pain may persist and evolve into postmastectomy pain syndrome (PMPS) in a significant subset of breast cancer survivors. In this retrospective investigation, we will present our experience in applying an interventional algorithmic approach to treat PMPS. DESIGN A retrospective study. SETTING An academic cancer hospital. SUBJECTS Adult females with PMPS diagnosis. METHODS We reviewed 169 records with the diagnosis of PMPS from 2015 to 2019 within our health system. Pre- and post-injection pain scores, relief duration, and medication usage changes were collected. The decision to perform each procedure was based on the anatomic location of the painful area with the corresponding peripheral sensory innervation. Decision-making flow diagrams were created to present our experience in managing PMPS beyond peripheral nerve blocks. RESULTS Ultrasound-guided peripheral nerve block results (n=350) were analyzed. The mean baseline pain score was 7, compared with the post-treatment mean score of 3 (95% confidence interval: 3.58 to 3.98, P = 0.0001). Among the responders, the mean pain relief duration was 45 days, with a median of 84 days. Opioid medication consumption was reduced by 11% (t = 0.72, P = 0.47). CONCLUSIONS Ultrasound-guided nerve blocks of this area could be performed safely and effectively after breast surgeries. We also present our proposed algorithm to provide a stepwise application for selecting the appropriate therapies in the management of more complex PMPS.
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Affiliation(s)
- Ajax Yang
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA.,The Spine and Pain Institute of New York, New York, USA
| | - Danielle Nadav
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA.,Department of Anesthesiology and Pain Medicine, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, New York, USA
| | - Aron Legler
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Grant H Chen
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Lee Hingula
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Vinay Puttanniah
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Amitabh Gulati
- Department of Anesthesiology and Critical Care, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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18
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Liu M, Yu W, Zhang F, Liu T, Li K, Lin M, Wang Y, Zhao G, Jiang J. Fe 3O 4@Polydopamine-Labeled MSCs Targeting the Spinal Cord to Treat Neuropathic Pain Under the Guidance of a Magnetic Field. Int J Nanomedicine 2021; 16:3275-3292. [PMID: 34007177 PMCID: PMC8123975 DOI: 10.2147/ijn.s296398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/17/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose Neuropathic pain causes great distress among patients; however, its response to traditional analgesia techniques remains sub-optimal. There has been progress in stem cell research for neuropathic pain treatment; however, effective homing remains problematic. This study aimed to establish Fe3O4@polydopamine(PDA)-labeled mesenchymal stem cells (MSCs); moreover, we aimed to guide MSCs using a magnetic field to the spinal cord segments showing pain-related responses to allow MSC homing and gathering, in advance, in order to fully employ their repair function. Materials and Methods Fe3O4@PDA-labeled MSCs were characterized using transmission electron microscopy. We analyzed the characteristics of MSCs, as well as the nanoparticle effects on MSC activity, differentiation, and proliferation, using the CCK-8 method, flow cytometry, and staining. Using rats, we performed behavioral tests of mechanical and thermal pain hypersensitivity. Serum inflammatory markers were detected using ELISA. Finally, changes in proteins associated with spinal cord pain were detected through quantitative reverse transcription PCR, histology, and immunohistochemistry. Results Fe3O4@PDA did not affect the characteristics and viability of MSCs. The magnetic field guidance improved the therapeutic effect of Fe3O4@PDA-labeled MSCs as indicated by the paw withdrawal threshold. Fe3O4@PDA-labeled MSCs decreased spinal nerve demyelination and c-Fos expression (a pain molecule); moreover, they inhibited microglia and astrocyte activation. Conclusion Fe3O4@PDA-labeled MSCs showed better homing to the spinal cord under magnetic field guidance. Moreover, they inhibited microglial and astrocyte activation, as well as played an early and continuous role in neuropathic pain treatment.
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Affiliation(s)
- Meichen Liu
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Weijia Yu
- Department of Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Fuqiang Zhang
- Department of Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Te Liu
- Department of Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Kai Li
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Meng Lin
- Department of Breast Surgery, The First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Ying Wang
- Department of Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Guoqing Zhao
- Department of Anesthesiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Jinlan Jiang
- Department of Scientific Research Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, People's Republic of China
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19
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Chalil A, Staudt MD, Harland TA, Leimer EM, Bhullar R, Argoff CE. A safety review of approved intrathecal analgesics for chronic pain management. Expert Opin Drug Saf 2021; 20:439-451. [PMID: 33583318 DOI: 10.1080/14740338.2021.1889513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Intrathecal (IT) drug therapy is an effective treatment option for patients with chronic pain of malignant or nonmalignant origin, with an established safety profile and fewer adverse effects compared to oral or parenteral pain medications. Morphine (a μ-opioid receptor agonist) and ziconotide (a non-opioid calcium channel antagonist) are the only IT agents approved by the U.S. Food and Drug Administration for the treatment of chronic pain. Although both are considered first-line IT therapies, each drug has unique properties and considerations.Areas Covered: This review will evaluate the pivotal trials that established the use of morphine and ziconotide as first-line IT therapy for patients with chronic pain, as well as safety and efficacy data generated from various retrospective and prospective studies.Expert Opinion: Morphine and ziconotide are effective IT therapies for patients with chronic malignant or nonmalignant pain that is refractory to other interventions. IT ziconotide is recommended as a first-line therapy due to its efficacy and avoidance of many adverse effects commonly associated with opioids. The use of IT morphine is also considered first-line; however, the risks of respiratory depression, withdrawal with drug discontinuation or pump malfunction, and the development of tolerance require careful patient selection and management.
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Affiliation(s)
- Alan Chalil
- Department of Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Michael D Staudt
- Department of Neurosurgery, Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA.,Michigan Head and Spine Institute, Southfield, Michigan, USA
| | - Tessa A Harland
- Department of Neurosurgery, Albany Medical College, Albany, New York, USA
| | - Elizabeth M Leimer
- Department of Anesthesiology & Perioperative Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Ravneet Bhullar
- Department of Anesthesiology, Albany Medical College, Albany, New York, USA
| | - Charles E Argoff
- Department of Neurology, Albany Medical College, Albany, New York
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20
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Matis G, De Negri P, Dupoiron D, Likar R, Zuidema X, Rasche D. Intrathecal pain management with ziconotide: Time for consensus? Brain Behav 2021; 11 Suppl 1:e02055. [PMID: 33690987 PMCID: PMC7943290 DOI: 10.1002/brb3.2055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/02/2020] [Accepted: 01/17/2021] [Indexed: 12/25/2022] Open
Abstract
This article summarizes recommendations made by six pain specialists who discussed the rationale for ziconotide intrathecal analgesia (ITA) and the requirement for evidence-based guidance on its use, from a European perspective. Riemser Pharma GmbH (Greifswald, Germany), which holds the European marketing authorization for ziconotide, hosted the meeting. The group agreed that ITA is under-used in Europe, adding that ziconotide ITA has potential to be a first-line alternative to morphine; both are already first-line options in the USA. Ziconotide ITA (initiated using a low-dose, slow-titration approach) is suitable for many patients with noncancer- or cancer-related chronic refractory pain and no history of psychosis. Adopting ziconotide as first-line ITA could reduce opioid usage in these patient populations. The group advocated a risk-reduction strategy for all candidate patients, including compulsory prescreening for neuropsychosis, and requested US-European alignment of the licensed starting dose for ziconotide: the low-and-slow approach practiced in the USA has a better tolerability profile than the fixed high starting dose licensed in Europe. Of note, an update to the European Summary of Product Characteristics is anticipated in early 2021. The group acknowledged that the Polyanalgesic Consensus Conference (PACC) treatment algorithms for ziconotide ITA provide useful guidance, but recommendations tailored specifically for European settings are required. Before a consensus process can formally begin, the group called for additional European prospective studies to investigate ziconotide in low-and-slow dosing strategies, in different patient settings. Such data would enable European guidance to have the most appropriate evidence at its core.
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Affiliation(s)
- Georgios Matis
- Department of Stereotactic and Functional NeurosurgeryFaculty of Medicine and University Hospital CologneUniversity of CologneCologneGermany
| | - Pasquale De Negri
- Department of Anaesthesia, Intensive Care and Pain MedicineSan Giuliano HospitalGiugliano, NaplesItaly
| | - Denis Dupoiron
- Anesthesiology and Pain DepartmentInstitut de Cancérologie de l’OuestICO Paul PapinAngersFrance
| | - Rudolf Likar
- Department of Anaesthesiology and Intensive CareKlagenfurt ClinicKlagenfurtAustria
| | - Xander Zuidema
- Department of Anaesthesiology and Pain MedicineDiakonessenhuis Utrecht/ZeistZeistThe Netherlands
| | - Dirk Rasche
- Functional Neurosurgery and Neurosurgical Pain TherapyUniversity Hospital Schleswig‐HolsteinLübeckGermany
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21
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[What became of Prialt®? : Observational study on the use of ziconotide in the treatment of chronic pain]. Schmerz 2021; 35:343-348. [PMID: 33507370 PMCID: PMC8452570 DOI: 10.1007/s00482-021-00531-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/04/2022]
Abstract
Hintergrund Prialt® ist seit Februar 2005 von der europäischen Arzneimittelbehörde zugelassen und ist neben Morphin das einzige Analgetikum, welches über die offizielle Marktzulassung in der intrathekalen Schmerztherapie verfügt. Da es nicht über Opioidrezeptoren wirkt, galt es zum Zeitpunkt der Markteinführung als nebenwirkungs- und risikoärmer in der Behandlung chronischer Schmerzen als Morphin. Trotzdem gilt es noch heute als Orphan Drug und Studien über den Langzeiteinsatz und hierunter aufgetretene Nebenwirkungen sind rar. Fragestellung Welchen Stellenwert nimmt Prialt® verglichen mit anderen intrathekal verabreichten Analgetika ein? Wie wirken sich die Startdosis und die Geschwindigkeit der Aufdosierung auf die schmerzlindernde Wirkung und das Auftreten von Nebenwirkungen in der Langzeittherapie aus? Material und Methoden Zum einen wurden anhand von Arztbriefen retrospektiv alle Patienten erfasst, die zwischen Februar 2005 und dem Ende des Beobachtungszeitraums im Oktober 2018 Ziconotid in Monotherapie in der Neurochirurgie des Universitätsklinikums Jena erhielten. Zum anderen wurden diese Patienten anhand eines erstellten Fragebogens hinsichtlich ihrer Erfahrung mit Ziconotid befragt. Ergebnisse Bei allen zwölf in die Studie eingeschlossenen Teilnehmern kam es zu mindestens einer Arzneimittelnebenwirkung. Am häufigsten wurde über Vergesslichkeit und Sensibilitätsstörungen mit jeweils 25 % berichtet. Ein Drittel der Patienten musste die Behandlung aufgrund von Nebenwirkungen beenden. Die mittlere Initialdosis betrug 1,98 µg/Tag. Diskussion Trotz leitliniengerechter Behandlung hat sich Ziconotid am Universitätsklinikum Jena nicht gegen Morphin und andere Opioidanalgetika in der intrathekalen Schmerztherapie durchgesetzt. Die Gründe hierfür sind vielfältig, wobei die enge therapeutische Breite, das häufige Auftreten von Nebenwirkungen und die schwierige therapeutische Handhabung, vor allem im ambulanten Setting, von besonderer Bedeutung sind.
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22
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Banik RK, Engle MP. Ziconotide for Management of Cancer Pain Refractory to Pharmacotherapy: An Update. PAIN MEDICINE 2020; 21:3253-3259. [PMID: 32940675 DOI: 10.1093/pm/pnaa251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Ratan K Banik
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota
| | - Mitchell P Engle
- Institute of Precision Pain Medicine, Corpus Christi, Texas, USA
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23
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Deer TR, Abd-Elsayed A, Falowski S, Hagedorn JM, Abejón D, Russo M, Engle A, Hah JM, Lamer TJ, Carayannopoulos AG, Hunter C, Steegers M, Pope J. Practice Choices in Targeted Intrathecal Drug Delivery: An Online Survey Conducted by the Polyanalgesic Consensus Committee. Neuromodulation 2020; 24:1139-1144. [PMID: 33368847 DOI: 10.1111/ner.13335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/18/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | - Alaa Abd-Elsayed
- University of Wisconsin Pain Clinic, Department of Anesthesiology, University of Wisconsin-Madison, Madison, WI, USA
| | - Steven Falowski
- Functional Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | | | - David Abejón
- Jefe de Departamento, Unidad de Dolor Grupo Quirón-Salud, Madrid, Spain
| | - Marc Russo
- Hunter Pain Specialists, Newcastle, Australia
| | - Alyson Engle
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jennifer M Hah
- Division of Pain Medicine, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Palo Alto, CA, USA
| | - Tim J Lamer
- Division of Pain Medicine, Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | - Alexios G Carayannopoulos
- Physical Medicine and Rehabilitation, Comprehensive Spine Center, Rhode Island Hospital, Providence, RI, USA.,Lifespan Physician Group, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Corey Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
| | - Monique Steegers
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jason Pope
- Evolve Restorative Center, Santa Rosa, CA, USA
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24
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Hale J, Prayson N, Liang C, Bolash R. Association Between Oral Pain Medications and Intrathecal Opioid Dose Escalation: A Retrospective Analysis. Neuromodulation 2020; 23:970-977. [PMID: 32596988 DOI: 10.1111/ner.13214] [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: 12/18/2019] [Revised: 04/26/2020] [Accepted: 05/10/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Patients treated with intrathecal therapy frequently require opioid dose increases to maintain analgesia. The kinetics of intrathecal opioid dose escalation are poorly understood. We hypothesized that antidepressant use, antiepileptic use, and lower baseline oral opioid intake prior to intrathecal pump implantation will be protective against intrathecal opioid dose escalation. MATERIALS AND METHODS Targeted drug delivery medication doses were collected from patients who had an intrathecal pump implanted between 2007 and 2016. From a sample size of 136 patients, the association between antidepressant, antiepileptic, and oral opioid use with intrathecal dose escalation was assessed using statistical models. RESULTS Individuals using an antiepileptic had an estimated ratio of means (97.5% CI) of opioid consumption of 0.91 (97.5% CI: [0.48, 1.73], p = 0.74) at six months, 0.83 ([0.43, 1.58], p = 0.51) at 12 months, and 0.77 ([0.40, 1.45], p = 0.36) at 24 months. Patients prescribed antidepressants had an estimated ratio of means (97.5% CI) of 1.43 ([0.77, 2.65], p = 0.19) at six months, 1.41 ([0.76, 2.63], p = 0.22) at 12 months, and 1.33 ([0.70, 2.51], p = 0.31) at 24 months. In our secondary analysis of pre-implant oral opioid use, patients treated with high oral opioid doses had a similar pattern of intrathecal dose escalation when compared to patients using low doses of oral opioids. CONCLUSIONS Use of antiepileptics, antidepressants, or low oral opioid doses was not associated with attenuation of intrathecal dose escalation. Intrathecal opioid dose escalation was observed to occur similarly, regardless of baseline oral analgesics concomitantly employed.
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Affiliation(s)
- Jason Hale
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Nicholas Prayson
- Anesthesiology Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Chen Liang
- Department of Outcomes Research, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Bolash
- Department of Pain Management and Evidence Based Pain Research, Cleveland Clinic Foundation, Cleveland, OH, USA
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25
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Intrathecal delivery of hydromorphone vs morphine for refractory cancer pain: a multicenter, randomized, single-blind, controlled noninferiority trial. Pain 2020; 161:2502-2510. [DOI: 10.1097/j.pain.0000000000001957] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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26
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McDowell GC, Saulino MF, Wallace M, Grigsby EJ, Rauck RL, Kim P, Vanhove GF, Ryan R, Huang IZ, Deer T. Effectiveness and Safety of Intrathecal Ziconotide: Final Results of the Patient Registry of Intrathecal Ziconotide Management (PRIZM). PAIN MEDICINE 2020; 21:2925-2938. [DOI: 10.1093/pm/pnaa115] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background and Objectives
The Patient Registry of Intrathecal Ziconotide Management evaluated the long-term effectiveness and safety of intrathecal ziconotide.
Methods
The study was a prospective, multicenter observational study of intrathecal ziconotide in US clinical practice. Patients were adults with severe chronic pain that warranted intrathecal therapy. Ziconotide was initiated as the single agent in the pump; however, other intrathecal medications were permitted. The primary efficacy outcome was ≥30% reduction in numeric pain rating scale score from baseline at week 12. A secondary outcome was patient global impression of change. Adverse events were solicited at each visit.
Results
The registry enrolled 93 patients. Seventy-four and 28 patients completed 12 weeks and 18 months of treatment, respectively. In the overall patient population, 17.4% had ≥30% pain reduction from baseline at week 12, with a mean reduction in pain of 10.9%. At month 18, 38.5% of patients had ≥30% pain reduction from baseline, with a mean pain reduction of 24.7%. Patient-rated improvement was reported in 67% of patients at week 12 and 71% at month 18. Almost all patients experienced adverse events, the most common of which were nausea (25.8%), confusional state (22.6%), and dizziness (20.4%).
Conclusions
Final study analyses showed that intrathecal ziconotide provided clinically meaningful pain relief in 17.4% and 38.5% of patients at week 12 and month 18, respectively. At these same time points, patient-rated improvement was reported in at least two-thirds of patients. The safety profile was consistent with that listed in the ziconotide prescribing information.
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Affiliation(s)
| | | | - Mark Wallace
- University of California, San Diego, La Jolla, California
| | | | - Richard L Rauck
- Carolinas Pain Institute, The Center for Clinical Research, Winston-Salem, North Carolina
| | - Philip Kim
- Center for Interventional Pain and Spine, LLC, Newark, Delaware
| | - Geertrui F Vanhove
- ‖
- Surrozen Inc, South San Francisco, California; **Jazz Pharmaceuticals, Palo Alto, California; ††Grail Inc, Menlo Park, California
| | - Robert Ryan
- ‖
- Surrozen Inc, South San Francisco, California; **Jazz Pharmaceuticals, Palo Alto, California; ††Grail Inc, Menlo Park, California
| | - I-Zu Huang
- ‖
- Surrozen Inc, South San Francisco, California; **Jazz Pharmaceuticals, Palo Alto, California; ††Grail Inc, Menlo Park, California
| | - Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, West Virginia, USA
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27
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Sindt JE, Odell DW, Dalley AP, Brogan SE. Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer. Neuromodulation 2020; 23:978-983. [PMID: 32459393 DOI: 10.1111/ner.13175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/06/2020] [Accepted: 04/22/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Pain is common in cancer, affecting more than 70% of patients with advanced disease. Intrathecal drug delivery systems (IDDS) are a well-established treatment for patients with refractory cancer pain, improving pain control and reducing associated side effects. To date, details of systemic opioid use before and after IDDS implant have not been reported. MATERIALS AND METHODS We conducted a retrospective review of patients at Huntsman Cancer Institute-University of Utah treated with IDDS for cancer pain from May 2014 to May 2018. Oral, transdermal, and parenteral opioid use before IDDS implant was compared to use 30 days postoperatively. RESULTS A total of 173 patients were included, 93% with stage IV disease. The pre-implant median daily oral morphine equivalent (OME) was 240 mg (interquartile range 130-390, range 0-2616 mg). OME doses >200 mg/day were required by 57% of patients, and >500 mg OME by 19% of patients. The post-implant median OME was 0 mg (interquartile range 0-0, range 0-480 mg) and 82.6% of patients discontinued systemic opioids completely. 11.0% of patients used <100 mg OME, and only 1.7% of patients used >200 mg OME. Mean OME decreased by 94% following IDDS implant (p < 0.0001) and all patients who continued to use systemic opioids required a lower OME compared to pre-implant. CONCLUSIONS In the largest cohort of patients with advanced cancer and refractory pain treated with IDDS, implantation was associated with a dramatic reduction in systemic opioid use 30 days postoperatively, with a large majority of patients discontinuing systemic opioids. Those patients that continued systemic opioids utilized significantly lower doses as compared to their pre-implant dose.
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Affiliation(s)
- Jill E Sindt
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Daniel W Odell
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Andrew P Dalley
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
| | - Shane E Brogan
- Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT, USA
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Lau J, Flamer D, Murphy-Kane P. Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review. Can J Anaesth 2020; 67:235-246. [PMID: 31571119 DOI: 10.1007/s12630-019-01482-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022] Open
Abstract
Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.
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Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, Toronto, ON, Canada.
| | - David Flamer
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, ON, Canada
- Toronto Western Hospital, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Patricia Murphy-Kane
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada
- Department of Nursing, Princess Margaret Cancer Center, Toronto, ON, Canada
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Qin W, Li Y, Liu B, Liu Y, Zhang Y, Zhang X, Li P, Fan B. Intrathecal Morphine Infusion Therapy via a Percutaneous Port for Refractory Cancer Pain in China: An Efficacy, Safety and Cost Utilization Analysis. J Pain Res 2020; 13:231-237. [PMID: 32021412 PMCID: PMC6987534 DOI: 10.2147/jpr.s233905] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 01/14/2020] [Indexed: 11/30/2022] Open
Abstract
Purpose Intrathecal morphine infusion therapy via a percutaneous port (IMITPP) has been used widely for its relatively low initial cost. However, there is scarce knowledge about IMITPP. In this study, we sought to evaluate efficacy, complications, and the interval required to achieve the cost equivalence of IMITPP in patients with refractory cancer pain in China. Patients and Methods A retrospective chart review was conducted on cancer patients who had received IMITPP at our hospital between April 2017 and April 2019. Data from the numeric pain rating scale and Karnofsky performance scores, and complications and costs related to IMITPP were collected from medical records. Daily analgesic costs before and after IMITPP were calculated based on the doses of opioids on admission and at discharge, respectively. The doses of systemic opioids before IMITPP were stratified into very high doses [VHD, oral morphine equivalent dose (OMED) >599 mg/day], high doses (HD, 300 mg/day ≤ OMED ≤ 599 mg/day), and regular doses (RD, OMED < 300 mg/day). Results Intrathecal morphine infusion therapy via a percutaneous port provided significant pain relief, but impaired activities of daily living in patients with refractory cancer pain. The commonly reported complications included nausea/vomiting and urinary retention, most of which were managed with symptomatic therapies. The median interval required to achieve cost equivalence was 11.44 months. The median intervals of VHD group and HD group were significantly shorter than that of RD group. Conclusion Intrathecal morphine infusion therapy via a percutaneous port provided effective cancer pain management without causing serious complications. Patients with higher doses of systemic opioids would economically benefit from IMITPP in a shorter time.
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Affiliation(s)
- Wangjun Qin
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Yifan Li
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Botao Liu
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Ying Liu
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Yi Zhang
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Xianglin Zhang
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Pengmei Li
- Department of Pharmacy, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Bifa Fan
- Department of Pain Management, China-Japan Friendship Hospital, Beijing, People's Republic of China
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Deer T, Hagedorn JM. How has ziconotide impacted non-cancer pain management? Expert Opin Pharmacother 2020; 21:507-511. [DOI: 10.1080/14656566.2019.1707182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Timothy Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
- President & CEO of the Centre for Pain Relief, Charleston, WV, USA
| | - Jonathan M. Hagedorn
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
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De Andrés J, Rubio-Haro R, De Andres-Serrano C, Asensio-Samper JM, Fabregat-Cid G. Intrathecal Drug Delivery. Methods Mol Biol 2020; 2059:75-108. [PMID: 31435916 DOI: 10.1007/978-1-4939-9798-5_3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Targeted intrathecal (IT) drug delivery systems (IDDS) are well established as an effective treatment of patients with chronic nonmalignant or malignant pain, and as a tool for management of patients with severe spasticity. The risk to benefit ratio of IDD makes it a relatively safe therapy for both cancer- and noncancer-related pain, but it is not free of risks, so it should be managed at specific centers. Recent technological advances, new therapeutic applications, reported complications, and the costs as well as maintenance required for this therapy require the need to stay up to date about new recommendations that may improve outcomes. This chapter reviews all technological issues regarding IDDS implantation with follow-up and pharmacological recommendations published during recent years that provide evidence-based decision-making process in the management of chronic pain and spasticity in patients.
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Affiliation(s)
- José De Andrés
- Unit of Anesthesia, Department of Surgical Specialties, Valencia University Medical School, Valencia, Spain. .,Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain.
| | - Rubén Rubio-Haro
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | | | - Juan Marcos Asensio-Samper
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
| | - Gustavo Fabregat-Cid
- Department of Anesthesiology, Critical Care and Pain Management, General University Hospital, Valencia, Spain
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Sica A, Casale B, Dato MTD, Calogero A, Spada A, Sagnelli C, Santagata M, Buonavolontà P, Fiorelli A, Salzano A, Dodaro CA, Martinelli E, Saracco E, Troiani T, Tammaro D, Ciardiello F, Papa A. Cancer- and Non-cancer Related Chronic Pain: From the Physiopathological Basics to Management. Open Med (Wars) 2019; 14:761-766. [PMID: 31637307 PMCID: PMC6795027 DOI: 10.1515/med-2019-0088] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 08/16/2019] [Indexed: 12/15/2022] Open
Abstract
The prevalence of chronic pain is between 33% to 64% and is due to cancer pain, but it has also been observed in non-cancer patients. Chronic pain is associated with lower quality of life and higher psychological distress and depressive/anxiety disorders in patients without a history of disorder. In this study we evaluated in clinical practice the effectiveness of the intrathecal pump in 140 patients who underwent pain therapy at our Center. These patients were consecutively enrolled from January 2010 to July 2018. Follow-up was carried out over these eight years regarding the infusion modalities. Pain relief was obtained in 71 (50,7%) patients out of the 140 that experienced satisfactory pain control globally. Intrathecal therapy is one of the best options for chronic severe refractory pain. The greatest advantage of this therapy is due to the possibility of treating the pain with minimal dosages of the drug, avoiding the appearance of troublesome side effects.
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Affiliation(s)
- Antonello Sica
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Beniamino Casale
- Department of Pneumology and Tisiology, AO Dei Colli - V. Monaldi, Naples, Italy
| | | | - Armando Calogero
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessandro Spada
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Caterina Sagnelli
- Department of Mental Health and Public Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Santagata
- Multidisciplinary Department of Medical Surgery and Dental Specialties, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Alfonso Fiorelli
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Anna Salzano
- Pain Department, AO Dei Colli - V. Monaldi, Naples, Italy
| | - Concetta Anna Dodaro
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Erika Martinelli
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Teresa Troiani
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Dario Tammaro
- Pain Department, AO Dei Colli - V. Monaldi, Naples, Italy
| | - Fortunato Ciardiello
- Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Alfonso Papa
- Pain Department, AO Dei Colli - V. Monaldi, Naples, Italy
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Deer TR, Pope JE, Hanes MC, McDowell GC. Intrathecal Therapy for Chronic Pain: A Review of Morphine and Ziconotide as Firstline Options. PAIN MEDICINE 2019; 20:784-798. [PMID: 30137539 PMCID: PMC6442748 DOI: 10.1093/pm/pny132] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Objectives To evaluate the evidence for morphine and ziconotide as firstline intrathecal (IT) analgesia agents for patients with chronic pain. Methods Medline was searched (through July 2017) for “ziconotide” or “morphine” AND “intrathecal” AND “chronic pain,” with results limited to studies in human populations. Results The literature supports the use of morphine (based primarily on noncontrolled, prospective, and retrospective studies) and ziconotide (based on randomized controlled trials and prospective observational studies) as first-choice IT therapies. The 2016 Polyanalgesic Consensus Conference (PACC) guidelines recommended both morphine and ziconotide as firstline IT monotherapy for localized and diffuse chronic pain of cancer-related and non–cancer-related etiologies; however, one consensus point emphasized ziconotide use, unless contraindicated, as firstline IT therapy in patients with chronic non–cancer-related pain. Initial IT therapy choice should take into consideration individual patient characteristics (e.g., pain location, response to previous therapies, comorbid medical conditions, psychiatric history). Trialing is recommended to assess medication efficacy and tolerability. For both morphine and ziconotide, the PACC guidelines recommend conservative initial dosing strategies. Due to its narrow therapeutic window, ziconotide requires careful dose titration. Ziconotide is contraindicated in patients with a history of psychosis. IT morphine administration may be associated with serious side effects (e.g., respiratory depression, catheter tip granuloma), require dose increases, and cause dependence over time. Conclusion Based on the available evidence, morphine and ziconotide are recommended as firstline IT monotherapy for cancer-related and non–cancer-related pain. The choice of first-in-pump therapy should take into consideration patient characteristics and the advantages and disadvantages of each medication.
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Affiliation(s)
- Timothy R Deer
- The Center for Pain Relief, Spine and Nerve Centers of The Virginias, Charleston, West Virginia
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Jain S, Malinowski M, Chopra P, Varshney V, Deer TR. Intrathecal drug delivery for pain management: recent advances and future developments. Expert Opin Drug Deliv 2019; 16:815-822. [PMID: 31305165 DOI: 10.1080/17425247.2019.1642870] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Chronic pain conditions of malignant and non-malignant etiology afflict a large group of the population and pose a vast economic burden on society. Intrathecal drug therapy is a viable treatment option in such patients who have failed conservative medical measures and less invasive pain management procedures. However, the clinical growth of intrathecal therapy in managing intractable chronic pain conditions continues to face many challenges and is likely underutilized secondary to its high-complexity and lack of understanding. Areas covered: This review will briefly discuss the history of intrathecal drug delivery systems (IDDS), cerebrospinal fluid (CSF) flow dynamics, types of IDDS, indications and patient profile suitable for this therapy, and risks and complications related to IDDS. We will also discuss challenges faced by physicians utilizing this therapy and the future changes that are needed for making this treatment modality more efficacious. Expert opinion: IDDS offer an effective therapy for pain control in patients suffering from chronic intractable pain conditions. These devices provide a safer alternative to oral opioid medications with reduced systemic side effects. Adherence to best practices and continued clinical and basic science research is important to ensure continuing success of this therapy.
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Affiliation(s)
- Sameer Jain
- a Pain Treatment Centers of America , Little Rock , AR , USA
| | - Mark Malinowski
- b Ohio University - HCOM , OH , USA.,c Adena Spine Center , Chillicothe , OH , USA
| | - Pooja Chopra
- d Department of Physical Medicine and Rehabilitation, University of Kentucky , Lexington , KY , USA
| | - Vishal Varshney
- e Division of Pain Medicine, Department of Anesthesiology, University of Calgary , Calgary , AB , Canada
| | - Timothy R Deer
- f Spine and Nerve Center of the Virginias , Charleston , WV , USA
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Kleinmann B, Wolter T. Managing Chronic Non-Malignant Pain in the Elderly: Intrathecal Therapy. Drugs Aging 2019; 36:789-797. [PMID: 31270686 DOI: 10.1007/s40266-019-00692-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Intrathecal drug delivery (IDD) was first described in 1981 by Onofrio, who used a pump for continuous and intrathecal delivery of morphine to treat cancer pain. Over the following four decades, many reports supported this treatment method with implanted pumps for cancer and non-cancer pain. To date, more than 300,000 pumps for pain therapy and spasticity have been implanted worldwide. This article reviews current knowledge regarding intrathecal opioid therapy, focusing particularly on the use of IDD in elderly patients. Current literature is presented, and the arguments in favor of and against this therapy in elderly patients are discussed.
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Affiliation(s)
- Barbara Kleinmann
- Interdisciplinary Pain Center, University of Freiburg, Faculty of Medicine, Breisacherstr. 64, 79106, Freiburg, Germany
| | - Tilman Wolter
- Interdisciplinary Pain Center, University of Freiburg, Faculty of Medicine, Breisacherstr. 64, 79106, Freiburg, Germany.
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Strategies for interventional therapies in cancer-related pain-a crossroad in cancer pain management. Support Care Cancer 2019; 27:3133-3145. [PMID: 31093769 DOI: 10.1007/s00520-019-04827-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 04/23/2019] [Indexed: 12/28/2022]
Abstract
PURPOSE Interventional therapies are important to consider when facing cancer pain refractory to conventional therapies. The objective of the current review is to introduce these effective strategies into dynamic interdisciplinary pain management, leading to an exhaustive approach to supportive oncology. METHODS Critical reflection based on literature analysis and clinical practice. RESULTS Interventional therapies act on the nervous system via neuromodulation or surgical approaches, or on primitive or metastatic lesions via interventional radiotherapy, percutaneous ablation, or surgery. Interventional therapies such as neuromodulations are constantly evolving with new technical works still in development. Nowadays, their usage is better defined, depending on clinical situations, and their impact on quality of life is proven. Nevertheless their availability and acceptability still need to be improved. To start with, a patient's interdisciplinary evaluation should cover a wide range of items such as patient's performance and psychological status, ethical considerations, and physiochemical and pharmacological properties of the cerebrospinal fluid for intrathecal neuromodulation. This will help to define the most appropriate strategy. In addition to determining the pros and cons of highly specialized interventional therapies, their relevance should be debated within interdisciplinary teams in order to select the best strategy for the right patient, at the right time. CONCLUSIONS Ultimately, the use of the interventional therapies can be limited by the requirement of specific trained healthcare teams and technical support, or the lack of health policies. However, these interventional strategies need to be proposed as soon as possible to each patient requiring them, as they can greatly improve quality of life.
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Dupoiron D, Leblanc D, Demelliez-Merceron S, Bore F, Seegers V, Dubois PY, Pechard M, Robard S, Delorme T, Jubier-Hamon S, Carvajal G, Lebrec N. Optimizing Initial Intrathecal Drug Ratio for Refractory Cancer-Related Pain for Early Pain Relief. A Retrospective Monocentric Study. PAIN MEDICINE 2019; 20:2033-2042. [DOI: 10.1093/pm/pnz096] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Abstract
Objective
Intrathecal (IT) drug delivery has shown its efficiency in treating refractory cancer pain, but switching opioids from the systemic to the intrathecal route is a challenging phase. Moreover, associations are widely used and recommended. Few data deal with the initial dosage of each drug. Analyzing conversion factors and initial dosages used in intrathecal therapy seems essential to decreasing the length of titration and to delivering quick pain relief to patients.
Methods
We retrospectively analyzed data from consecutive adult patients implanted with an intrathecal device for cancer pain and treated at the Institut de Cancérologie de l’Ouest, in Angers, France, for four years. The main goal was to identify factors associated with early pain relief after intrathecal drug delivery system (IDDS) implantation.
Results
Of the 220 IDDS-treated patients, 70 (32%) experienced early pain relief (EaPR) and 150 (68%) delayed pain relief (DePR). Performance Status stage and initial IT ropivacaine:IT morphine ratio were the variables independently associated with EaPR. The best IT ropivacaine:IT morphine ratio to predict EaPR was 5:1, with a 73% (95% confidence interval [CI] = 64.8% to 79.6%) sensitivity and a 67.1% (95% CI = 54.9% to 77.9%) specificity. EaPR subjects experienced better pain relief (–84% vs –60% from baseline pain score, P < 0.0001), shorter length of hospitalization (7 vs 10 days, P < 0.0001), and longer survival (155 vs 82 days, P = 0.004).
Conclusions
Local anesthetic:morphine ratio should be considered when starting IDDS treatment. EaPR during the IT analgesia titration phase was associated with better pain relief and outcomes in patients with refractory cancer-related pain.
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Affiliation(s)
- Denis Dupoiron
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Damien Leblanc
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | | | - Francois Bore
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Valerie Seegers
- Research and Statistics Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Pierre Yves Dubois
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Marie Pechard
- Anesthesiology and Pain Department, Institut Curie, Paris, France
| | - Serge Robard
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest R. Gauducheau, St Herblain, France
| | - Thierry Delorme
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Sabrina Jubier-Hamon
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Gabriel Carvajal
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
| | - Nathalie Lebrec
- Anesthesiology and Pain Department, Institut de Cancerologie de l’Ouest Paul Papin, Angers, France
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Sukul VV. Intrathecal Pain Therapy for the Management of Chronic Noncancer Pain. Neurosurg Clin N Am 2019; 30:195-201. [DOI: 10.1016/j.nec.2018.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Careskey H, Narang S. Interventional Anesthetic Methods for Pain in Hematology/Oncology Patients. Hematol Oncol Clin North Am 2019; 32:433-445. [PMID: 29729779 DOI: 10.1016/j.hoc.2018.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This article reviews anesthetic interventional approaches to the management of pain in hematology and oncology patients. It includes a discussion of single interventions including peripheral nerve blocks, plexus injections, and sympathetic nerve neurolysis, and continuous infusion therapy through implantable devices, such as intrathecal pumps, epidural port-a-caths, and tunneled catheters. The primary objective is to inform members of hematology and oncology care teams regarding the variety of interventional options for patients with cancer-related pain for whom medical pain management methods have not been effective.
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Affiliation(s)
- Holly Careskey
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Sanjeet Narang
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
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40
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Herring EZ, Frizon LA, Hogue O, Mejia JU, Rosenquist R, Bolash RB, Machado AG, Nagel SJ. Long-term Outcomes Using Intrathecal Drug Delivery Systems in Complex Regional Pain Syndrome. PAIN MEDICINE 2018; 20:515-520. [DOI: 10.1093/pm/pny104] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Eric Z Herring
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Jay U Mejia
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | | | - Andre G Machado
- Center for Neurological Restoration
- Department of Neurosurgery, Cleveland Clinc, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration
- Department of Neurosurgery, Cleveland Clinc, Cleveland, Ohio, USA
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Bäckryd E. Do the potential benefits outweigh the risks? An update on the use of ziconotide in clinical practice. Eur J Pain 2018; 22:1193-1202. [DOI: 10.1002/ejp.1229] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2018] [Indexed: 01/17/2023]
Affiliation(s)
- E. Bäckryd
- Pain and Rehabilitation Centre; Department of Medical and Health Sciences; Linköping University; Linköping Sweden
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42
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McDowell GC, Winchell J. Role of primary care physicians in intrathecal pain management: a narrative review of the literature. Postgrad Med 2018. [PMID: 29542370 DOI: 10.1080/00325481.2018.1448207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVES The majority of patients seeking medical care for chronic pain consult a primary care physician (PCP). Because systemic opioids are commonly prescribed to patients with chronic pain, PCPs are attempting to balance the competing priorities of providing adequate pain relief while reducing risks for opioid misuse and overdose. It is important for PCPs to be aware of pain management strategies other than systemic opioid dose escalation when patients with chronic pain fail to respond to conservative therapies and to initiate a multimodal treatment plan. METHODS The Medline database and evidence-based treatment guidelines were searched to identify publications on intrathecal (IT) therapy for the management of chronic pain. Selection of publications relevant to PCPs was based on the authors' clinical and research expertise. RESULTS IT administration delivers analgesic medication directly into the cerebrospinal fluid, avoiding first-pass effect and bypassing the blood-brain barrier, thereby requiring lower medication doses. Morphine, a µ-opioid receptor agonist, and ziconotide, a non-opioid, selective N-type calcium channel blocker, are the only analgesics approved by the US Food and Drug Administration to treat chronic refractory pain by the IT route. Patients who are potential candidates for IT therapy may benefit from evaluation by an interventional pain physician. PCPs can play an important role in patient selection and referral for IT therapy and provide ongoing collaborative care for patients receiving IT therapy, including monitoring for efficacy and adverse events and facilitating communication with the treating specialist. CONCLUSIONS Collaboration between PCPs and pain specialists may improve outcomes of and patient satisfaction with IT therapy and other interventional treatments.
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Intrathecal Drug Delivery and Spinal Cord Stimulation for the Treatment of Cancer Pain. Curr Pain Headache Rep 2018; 22:11. [DOI: 10.1007/s11916-018-0662-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Galica RJ, Hayek SM, Veizi E, McEwan MT, Katta S, Ali O, Aziz N, Sondhi N. Intrathecal Trialing of Continuous Infusion Combination Therapy With Hydromorphone and Bupivacaine in Failed Back Surgery Patients. Neuromodulation 2017; 21:648-654. [PMID: 29206315 DOI: 10.1111/ner.12737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Revised: 09/17/2017] [Accepted: 10/14/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Intrathecal (IT) trial is a prognostic interventional pain management procedure employed to determine the potential success of treating intractable pain with an implantable infusion device system. There is a dearth of data regarding trials with continuous infusion of combination therapy (e.g. opioid combined with local anesthetic). The objective of the this study was to determine the overall outcomes of continuous infusion IT trials and factors influencing long-term success of IT therapy in patients with chronic intractable pain post-laminectomy. MATERIALS AND METHODS This is a retrospective analysis of all patients with lumbar failed back surgery syndrome (FBSS) who were trialed with a combination of hydromorphone and bupivacaine with a temporary externalized IT catheter from March 2007 to June 2014. RESULTS From a cohort of 62 patients fulfilling the inclusion criteria, 54 (87.10%) patients had successful IT trials. No significant differences were found between successful and failed trial patients with regards to age, sex, pre-trial pain numeric rating scale scores, pre-trial morphine equivalent daily dose, or trial dosages. Significant positive correlations were found between pretrial oral opioid intake and end of trial hydromorphone dose and hydromorphone dose escalation at 12 months and 24 months. CONCLUSIONS Patients with refractory low back pain due to FBSS who underwent successful combination IT trial with hydromorphone and bupivacaine infused through a temporary IT catheter had significantly improved pain intensity scores following permanent implant. Higher pre-trial MEDD was correlated with higher trial and post-implant opioid doses and higher rates of opioid dose escalation post-implant.
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Affiliation(s)
- Ryan J Galica
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Salim M Hayek
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Elias Veizi
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA.,Cleveland Veterans Administration Medical Center, Cleveland, OH, USA
| | - Matthew T McEwan
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Sivakanth Katta
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Omar Ali
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Nida Aziz
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
| | - Nidhi Sondhi
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA.,Case Western Reserve University, Cleveland, OH, USA
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Abstract
Objective Physician assistants (PAs), nurse practitioners (NPs), and registered nurses (RNs) provide professional services on pain management teams. This review provides an overview of the practical management of chronic pain with intrathecal (IT) therapy using an interprofessional approach (eg, physicians and other health care professionals), with a focus on the contributions of PAs, NPs, and RNs. Methods Narrative review based on literature searches of the Medline database and treatment guidelines on the use of IT therapy in the management of patients with chronic pain. Results The specific roles and responsibilities of PAs, NPs, and RNs in the management of patients receiving IT therapy vary by practice. In many pain treatment centers, PAs, NPs, and RNs are responsible for patient education, postimplant maintenance, and ongoing supportive care of patients receiving IT therapy. Topics that we address include patient selection, patient expectations and goal setting, medication selection, outcome assessment, and treatment adjustment. Currently, morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker) are the only agents approved by the US Food and Drug Administration for IT analgesia. We provide relevant information on the dosing, titration, and adverse effect management of these medications for PAs, NPs, and RNs responsible for administering IT therapy. Conclusion PAs, NPs, and RNs are valuable members of IT pain management teams. Treatment success requires ongoing monitoring of efficacy and adverse effects, with corresponding adjustments to medication selection and dosing, in addition to good communication among the health care professionals involved in patient care.
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Affiliation(s)
| | - Neona M Lotz
- Cypress Ambulatory Surgery Center, Santa Maria, CA, USA
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Levy RM. Evidence Based Medicine vs. Expert Consensus in Medical Guidelines: An Artificial Conflict. Neuromodulation 2017; 20:93-95. [PMID: 28168826 DOI: 10.1111/ner.12578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Robert M Levy
- Boca Raton, Florida.,Neuromodulation: Technology at the Neural Interface, San Francisco, CA
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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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Deer TR, Pope JE, Hayek SM, Bux A, Buchser E, Eldabe S, De Andrés JA, Erdek M, Patin D, Grider JS, Doleys DM, Jacobs MS, Yaksh TL, Poree L, Wallace MS, Prager J, Rauck R, DeLeon O, Diwan S, Falowski SM, Gazelka HM, Kim P, Leong M, Levy RM, McDowell II G, McRoberts P, Naidu R, Narouze S, Perruchoud C, Rosen SM, Rosenberg WS, Saulino M, Staats P, Stearns LJ, Willis D, Krames E, Huntoon M, Mekhail N. The Polyanalgesic Consensus Conference (PACC): Recommendations on Intrathecal Drug Infusion Systems Best Practices and Guidelines. Neuromodulation 2017; 20:96-132. [DOI: 10.1111/ner.12538] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/23/2016] [Accepted: 05/23/2016] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | - Anjum Bux
- Anesthesia and Chronic Pain Management; Ephraim McDowell Regional Medical Center; Danville KY USA
| | - Eric Buchser
- Anaesthesia and Pain Management Department; EHC Hosptial, Morges, and CHUV University Hospital; Lausanne Switzerland
| | - Sam Eldabe
- The James Cook University Hospital; Middlesbrough UK
| | - Jose A. De Andrés
- Valencia School of Medicine; Hospital General Universitario; Valencia Spain
| | - Michael Erdek
- Anesthesiology and Critical Care Medicine; Johns Hopkins University School of Medicine; Baltimore MD USA
| | | | - Jay S. Grider
- University of Kentucky College of Medicine, UK HealthCare Pain Services; Lexington KY USA
| | | | | | - Tony L. Yaksh
- Anesthesiology and Pharmacology; University of California; San Diego CA USA
| | - Lawrence Poree
- Pain Clinic of Monterey Bay, University of California at San Francisco; San Francisco CA USA
| | | | - Joshua Prager
- Center for the Rehabilitation Pain Syndromes (CRPS) at UCLA Medical Plaza; Los Angeles CA USA
| | - Richard Rauck
- Carolina Pain Institute, Wake Forest Baptist Health; Winston-Salem NC USA
| | - Oscar DeLeon
- Roswell Park Cancer Institute, SUNY; Buffalo NY USA
| | - Sudhir Diwan
- Manhattan Spine and Pain Medicine; Lenox Hill Hospital; New York NY USA
| | | | | | - Philip Kim
- Bryn Mawr Hospital; Bryn Mawr PA, USA
- Christiana Hospital; Newark DE USA
| | | | | | | | | | - Ramana Naidu
- San Francisco Medical Center, University of California; San Francisco CA USA
| | - Samir Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | - Peter Staats
- Premier Pain Management Centers; Shrewsbury NJ, USA
- Johns Hopkins University; Baltimore MD USA
| | | | | | - Elliot Krames
- Pacific Pain Treatment Center (ret.); San Francisco CA USA
| | - Marc Huntoon
- Vanderbilt University Medical Center; Nashville TN USA
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Duarte RV, Lambe T, Raphael JH, Eldabe S, Andronis L. Intrathecal drug delivery systems for the management of chronic non-cancer pain: protocol for a systematic review of economic evaluations. BMJ Open 2016; 6:e012285. [PMID: 27421298 PMCID: PMC4964247 DOI: 10.1136/bmjopen-2016-012285] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Intrathecal drug delivery (ITDD) systems are an option for the management of patients with chronic non-cancer pain, cancer pain and spasticity. Concerns over their invasiveness and high initial costs have led National Health Service (NHS) England to decommission ITDD for patients with chronic non-cancer pain. However, the extent to which this decision is in line with existing economic evidence is unclear. To address this question, we will carry out a systematic review to identify and evaluate the existing evidence on the cost-effectiveness of ITDD for chronic non-cancer pain. METHODS AND ANALYSIS A high-sensitivity search strategy will be employed in Cochrane Library, MEDLINE, EMBASE, Web of Science, NHS EED, DARE and HTA. Database searches will be complemented by additional searching techniques. Screening of the results will be performed by 2 reviewers independently using predetermined inclusion and exclusion criteria. Full and partial economic evaluations will be included. Data extraction will be carried out using a form created for the purposes of this review. Quality assessment of all included studies will be performed using recommended checklists. ETHICS AND DISSEMINATION Ethical approval is not required as primary data will not be collected. Findings will be disseminated through peer-reviewed publications and conference presentations. PROSPERO REGISTRATION NUMBER CRD42016035266.
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Affiliation(s)
- Rui V Duarte
- Department of Public Health, Epidemiology and Biostatistics, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Tosin Lambe
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Jon H Raphael
- Faculty of Health, Birmingham City University, Birmingham, UK
- Department of Pain Management, Russells Hall Hospital, Dudley, UK
| | - Sam Eldabe
- Department of Pain and Anaesthesia, The James Cook University Hospital, Middlesbrough, UK
| | - Lazaros Andronis
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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