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Health Sciences Assistant Clinical Professor of Pharmacy, Department of Clinical Pharmacy, University of California, San Francisco, CA
Health Sciences Assistant Clinical Professor of Pharmacy, Department of Clinical Pharmacy, University of California, San Francisco
at time of writing, Clinical Pharmacist— Drug Information, Blue Shield of California Pharmacy Services; now, Product Evaluation Pharmacist—Drug Information Services, Kaiser Permanente, Oakland, CA
Reprints: Dr. Lynch, Department of Clinical Pharmacy, University of California, San Francisco, Box 0622, C-152, 521 Parnassus Ave., San Francisco, CA 94143-0622, fax 415/476-6632, lynchs{at}pharmacy.ucsf.edu
OBJECTIVE: To describe the pharmacology, efficacy, and safety of ziconotide for treatment of severe chronic pain in patients who are candidates for intrathecal therapy.
DATA SOURCES: A PubMed/MEDLINE search (1966-June 2006) was conducted using the terms ziconotide, Prialt, and SNX-111. Manufacturer-provided data, the Food and Drug Administration medical review of ziconotide, and abstracts presented at American Pain Society meetings (2001-2006) were also reviewed.
STUDY SELECTION AND DATA EXTRACTION: Human studies evaluating the efficacy and safety of ziconotide for the treatment of chronic pain were considered. Animal data were excluded.
DATA SYNTHESIS: Ziconotide is the first and only neuronal-type (N-type) calcium-channel blocker. Ziconotide must be administered intrathecally via continuous infusion. A programmable implanted variable-rate microinfusion device, or an external microinfusion device and catheter must be utilized. In double-blind, placebo-controlled studies, ziconotide significantly improved patient perception of pain from baseline to the end of the study periods, which ranged from 11 to 21 days. Patients enrolled in clinical trials were intolerant of or refractory to other treatment modalities. There have been no studies that directly compared ziconotide with other intrathecal or systemic analgesics. Key ziconotide-related adverse events are neuropsychiatric, including depression, cognitive impairment, and hallucinations; depressed levels of consciousness; and elevation of creatine kinase levels. Ziconotide is also associated with a risk of meningitis due to possible contamination of the microinfusion device.
CONCLUSIONS: Ziconotide is a therapeutic option for treatment of severe chronic pain in patients who have exhausted all other agents, including intrathecal morphine, and for whom the potential benefit outweighs the risks of serious neuropsychiatric adverse effects and of having an implanted device. Further studies are needed to determine the comparative efficacy of ziconotide and other pain therapies.
Key Words: chronic pain, intrathecal, N-type calcium-channel blocker, refractory pain, ziconotide
Published Online, July 11, 2006. www.theannals.com, DOI 10.1345/aph.1G584
THIS ARTICLE IS APPROVED FOR CONTINUING EDUCATION CREDIT
ACPE UNIVERSAL PROGRAM NUMBER: 407-000-06-014-H01
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