Safety and efficacy of intrathecal ziconotide in the management of severe chronic pain

Figures & data

Table 1 Recommended algorithm for intrathecal polyanalgesic therapies, 2007

(a) ↔ (b) ↔ (c)

Line #1 (a) morphine, (b) hydromorphone, (c) ziconotide

(d) ↔ (e) ↔ (f)

Line #2: (d) fentanyl, (e) morphine/hyromorphone + ziconotide, (f) morphine/hydromorphone + bupivacaine/clonidine

(g) ↔ (h)

Line #3: (g) clonidine, (h) morphine/hydromorphone/fentanyl bupivacaine +clonidine + ziconotide

(i) ↔ (j)

Line #4*: (i) sufentanil, (j) sufentanil + bupivacaine +/clonidine + ziconotide

(k)

Line #5: (k) ropivacaine, buprenorphine, midazolam meperidine, ketorolac

(l)

Line #6: Experimental drugs (l) gabapentin, octreotide, conopeptide, neostigmine, adenosine,

XeN2174, AM336, XeN, ZGX 160

Notes: Line 1: Morphine (a) and ziconotide (c) are approved by the US Food and Drug Administration for intrathecal analgesic use and are recommended for first-line for nociceptive, mixed, and neuropathic pain. Hydromorphone (b) is recommended based on clinical widespread usage and apparent safety.

Line 2: Because of its apparent granuloma-sparing effect and because of its wide apparent use and identified safety, fentanyl (d) has been upgraded to a line 2 agent by the consensus conference when the use of the more hydrophilic agents of line 1 (a,b) result in intractable supraspinal side-effects. Combinations of opioid + ziconotide (e) or opioid + bupivacaine or clonidine (f) are recommended for mixed and neuropathic pain and may be used interchangeably. When admixing opioids with ziconotide, attention must be made to the guidelines for admixing ziconotide with other agents.

Line 3: Clonidine (g) alone or opioids such as morphine/hydromorphone/fentanyl with bupivacaine and/or clonidine mixed with ziconotide (h) may be used when agents in line 2 fail to provide analgesia or side-effects occur when these agents are used.

Line 4: Because of its proven safety in animals and humans and because of its apparent granuloma-sparing effects, sufentanil alone (i) or mixed with bupivacaine and/or clonidine plus ziconotide (j) is recommended in this line. The addition of clonidine, bupivacaine, and or ziconotide is to be used in patients with mixed or neuropathic pain. *In patients with end of life, the panelists felt that midazolam and octreotide should be tried when all other agents in lines 1 4 have failed.

Line 5: These agents (k), although not experimental, have little information about them in the literature and use is recommended with caution and obvious informed consent regarding the paucity of information regarding the safety and efficacy of their use.

Line 6: experimental agents (l) must only be used experimentally and with appropriate independent Review Board (iRB) approved protocols.³²

WallaceMSZiconotide: a new nonopioid intrathecal analgesic for the treatment of chronic painExpert Rev Neurother20066101423142817078783

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