Polyanalgesic Consensus Conference-2012: Recommendations to Reduce Morbidity and Mortality in Intrathecal Drug Delivery in the Treatment of Chronic Pain

Johns Hopkins University, Baltimore, MD, USA
Neuromodulation (Impact Factor: 2.7). 07/2012; 15(5):467-482. DOI: 10.1111/j.1525-1403.2012.00486.x
Source: PubMed


Targeted intrathecal drug infusion to treat moderate to severe chronic pain has become a standard part of treatment algorithms when more conservative options fail. This therapy is well established in the literature, has shown efficacy, and is an important tool for the treatment of both cancer and noncancer pain; however, it has become clear in recent years that intrathecal drug delivery is associated with risks for serious morbidity and mortality.

The Polyanalgesic Consensus Conference is a meeting of experienced implanting physicians who strive to improve care in those receiving implantable devices. Employing data generated through an extensive literature search combined with clinical experience, this work group formulated recommendations regarding awareness, education, and mitigation of the morbidity and mortality associated with intrathecal therapy to establish best practices for targeted intrathecal drug delivery systems.

Best practices for improved patient care and outcomes with targeted intrathecal infusion are recommended to minimize the risk of morbidity and mortality. Areas of focus include respiratory depression, infection, granuloma, device-related complications, endocrinopathies, and human error. Specific guidance is given with each of these issues and the general use of the therapy.

Targeted intrathecal drug delivery systems are associated with risks for morbidity and mortality that can be devastating. The panel has given guidance to treating physicians and healthcare providers to reduce the incidence of these problems and to improve outcomes when problems occur.

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    • "The formation of granulomas in intrathecal catheters has been reported to have a 0.04% occurrence rate two years after insertion of the catheter and 1.15% six years after insertion [24]. Overall incidence has been reported to be less than 1% but probably the incidence of this complication is underreported in literature [21,24]. "
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    ABSTRACT: Intrathecal drug delivery is an effective and safe option for the treatment of chronic pathology refractory to conventional pain therapies. Typical intrathecal administered drugs are opioids, baclofen, local anesthetics and adjuvant medications. Although knowledge about mechanisms of action of intrathecal drugs are every day more clear many doubt remain respect the correct location of intrathecal catheter in order to achieve the best therapeutic result. We analyze the factors that can affect drug distribution within the cerebrospinal fluid. Three categories of variables were identified: drug features, cerebrospinal fluid (CSF) dynamics and patients features. First category includes physicochemical properties and pharmacological features of intrathecal administered drugs with special attention to drug lipophilicity. In the second category, the variables in CSF flow, are considered that can modify the drug distribution within the CSF with special attention to the new theories of liquoral circulation. Last category try to explain inter-individual difference in baclofen response with difference that are specific for each patients such as the anatomical area to treat, patient posture or reaction to inflammatory stimulus. We conclude that a comprehensive evaluation of the patients, including imaging techniques to study the anatomy and physiology of intrathecal environment and CSF dynamics, could become essential in the future to the purpose of optimize the clinical outcome of intrathecal therapy.
    Full-text · Article · Oct 2013 · The Korean journal of pain

  • No preview · Article · Sep 2012 · Neuromodulation
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    ABSTRACT: A substantial body of evidence (including in vitro and in vivo pharmacology using selective N-type blockers and studies using CaV2.2 knockout mouse strains) implicates CaV2.2 as the major presynaptic VDCC underlying glutamate and neuropeptide release from sensory terminals in the dorsal horn of the spinal cord. In addition, data is emerging to support a key role of VDCC alpha2delta (α2δ) accessory subunits as modulators of presynaptic VDCC function and regulators of synaptic release. The successful use of the α2δ-1 ligands, gabapentoids, to treat fibromyalgia and diabetic neuropathy and the development of the ω-conopeptide ziconotide, a CaV2.2 blocker with clinical efficacy demonstrated in a range of chronic pain disorders has established presynaptic VDCCs as key pain drug discovery targets. This chapter will outline current understanding of the role of presynaptic VDCCs in pain signalling, discuss efforts to develop ω-conopeptides and small molecule inhibitors of CaV2.2 as novel analgesics and review mechanism of action and clinical use of gabapentinoids and ω-conotoxins. © Springer Science+Business Media Dordrecht 2013. All rights are reserved.
    No preview · Chapter · Jan 2013
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