Additional Pearls

Morphine and hydromorphone are stable up to 90 days, the maximum refill interval even if a patient is on small doses (Hildebrand et al. 2001, Hildebrand et al. 2003, Classen et al. 2004).

Ziconotide is additional Food and Drug Administration (FDA)-approved medication for intrathecal use. It is a calcium channel blocker which has been shown to be useful in neuropathic pain where other treatments have failed. Psychiatric side effects may limit its use.

Baclofen is a gamma aminobutyric acid (GABA) agonist used for the treatment of spas-ticity and pain. It is administered both oral and intrathecal routes. If patient symptoms are unresponsive to maximum oral doses, an intrathecal baclofen trial may be performed. After 50-100 mcg of baclofen is injected by spinal, the response, which is variable, is then serially measured and quantified using the Ashworth scale. Significant improvement may be treated with an intrathecal delivery system. Pump malfunction is an emergency, since baclofen withdrawal can be life threatening.

Table 13.3 Recommended algorithm for intrathecal polyanalgesic therapies. Progression begins from first line initial medications through sixth line which are experimental medications.

Line 1

(a) Morphine 4 ►

(b)Hydromorphone M ►

(c)Ziconotide

Line 2

(d) Fentanyl

(e) Morphine/hydromorphone M ► + ziconotide

(f) Morphine/ hydromorphone + bupivacaine/clonidine

Line 3

(d) Clonidine

(h) Morphine/hydromorphone/fentanyl Bupivacaine + clonidine + ziconotide

Line 4

(i) Sufentanil

(j)Sufentanil + bupivacaine + clonidine + ziconotide

Line 5

(k) Ropivacaine, buprenorphine, midazolam Meperidine, ketorolac

Line 6

Experimental drugs Gabapentin, octreotide

Conopeptide, neostigmine, adenosine

XEN2174, AM336, XEN, ZGX 160

Adapted from Racz (2008).

Adapted from Racz (2008).

Table 13.4 Percent of physicians using different medications/combinations for intrathecal pumps.

% of Surgeons

Low

High

(total sample

managers

managers

Mean #

# of

%

Drug

n = 413)

(n = 199)

(n = 214)

patients

Patients

Patients

Morphine alone

99

99

98

15.5

6339

48

Morphine + bupivacaine

68

55

80

5.9

1649

12

Hydromorphone alone

58

48

67

4.7

1142

8

Morphine + clonidine

55

44

66

4.8

1099

8

Hydromorphone +

35

26

44

3.9

566

4

bupivacaine

Morphine + clonidine +

34

22

48

5

700

5

bupivacaine

Morphine + baclofen

34

21

46

2.8

395

3

Fentanyl alone

21

13

29

2.4

212

1

Clonidine alone

21

12

30

1.9

168

1

Sufentanil alone

16

8

23

2.3

153

1

Other

24

19

29

9.2

919

7

Adapted from Geurts (2002).

Adapted from Geurts (2002).

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