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Antitubulin Agents
Published in David E. Thurston, Ilona Pysz, Chemistry and Pharmacology of Anticancer Drugs, 2021
Finally, it is important that administration techniques are carefully managed for this family of agents because all members can cause severe local irritation at the injection site. Therefore, extravasation must be avoided. Also, inadvertent intrathecal administration can cause severe neurotoxicity, which is usually fatal.
Psychiatric Treatment Approaches for Pediatric Pain
Published in Andrea Kohn Maikovich-Fong, Handbook of Psychosocial Interventions for Chronic Pain, 2019
Clonidine, an α-2 adrenergic agonist, commonly is used for several psychiatric symptoms in addition to pain management. Several findings show benefits for neuropathic pain, benefits thought to be based on alterations in the responsiveness of descending pain circuits that modulate peripheral processing and sensory input (Manelli et al., 2017). Clonidine and other central α-2 agonists are thought to target these projections and impact the hyperalgesia associated with neuropathic pain and other pain disorders. Intrathecal administration occasionally is used to target severe chronic pain.
The development and practice of palliative care
Published in John Lombard, Law, Palliative Care and Dying, 2018
Palliative medication may be administered in a number of different ways including injection, oral, suppository or through intrathecal pump. The intrathecal pump functions by delivering ‘small doses of medication directly to the spinal fluid’.192 This has the effect of increasing the ‘relative strength of the drug compared to its oral or intravenous equivalent’.193 This approach can minimise potential side effects of sedative drugs. The control exercised over the administration of sedative drugs is important due to the harmful consequences associated with an excessive dose. Naturally, it follows that sedation should be the ‘lowest necessary to provide adequate relief of suffering’.194 In the context of morphine it appears that when it is administered at such a level there is ‘little data to support the belief that appropriate use of opioids hastens death in patients dying from cancer and other chronic diseases’.195 The challenge which this presents is the identification of what constitutes an appropriate level of sedative. This level will vary over the course of a patient’s care, for example, after the initial sedation the risk of hastening death decreases. This is based on the fact that the ‘risk of respiratory depression is greatest when opioids are first begun’.196 As treatment progresses, the ability of a patient to cope with respiratory side effects increases,197 but over time toxicity may occur.
Prepontine cisternal routine for intrathecal targeted drug delivery in craniofacial cancer pain treatment: technical note
Published in Drug Delivery, 2022
Haocheng Zhou, Dong Huang, Dingquan Zou, Junjiao Hu, Xinning Li, Yaping Wang
In the end stage of tumor, one hallmark feature of cancer-related pain is the excruciating pain, that is insufficiently treated by oral analgesic medications. Likely, both cases presented with severe pain (8/10 VAS) at resting state and the worst suffering during breakthrough pain episodes, with considerable amounts of opioids consuming up to 380 and 790 mg equivalent morphine in 24 hours. Despite unsatisfactory control of pain, multiple side effects of analgesic effect are frequently reported, including dizziness, nausea, vomiting, constipation and physical dependence (Benyamin et al., 2008). One advantage of intrathecal therapy is the significant reduction of opioids intake, which may attenuate the side reaction. Oral opioids were totally replaced one week after implantation procedure in the first patient, and the intrathecal titration was completed one month after discharge for the other case. The daily cisternal amount of morphine ranged between 1.9 and 3.0 mg, accounting for about 0.05% of oral dosage. This data is consistent with the conventional 300:1 ratio (Sylvester et al., 2004). In addition to conversion ratio, one key parameter of intrathecal therapy is the pharmacratic formation. Combination of local anesthetics (bupivacaine) with morphine may contribute to provide supplementary pain control for the intractable cases (van Dongen et al., 1999). In this study, both cases achieved sufficient relief with prepontine cisternal morphine delivery.
The use of alternative therapies in conjunction with opioids for cancer pain
Published in Expert Review of Anticancer Therapy, 2019
Sebastiano Mercadante, Kenneth D. Candido
The analgesic agent is delivered from an implanted device or an external pump. This modality of drug administration allows for direct access to central nervous system receptors, bypassing issues of drug absorption from the gastrointestinal tract and loss of efficacy of opioids from first pass metabolism. Opioids are the most commonly used medications, although several other medications have been used. The simplest delivery system involves a catheter inserted into the intrathecal space percutaneously and connected to an external infusion pump. The advantages of such delivery system include ease of insertion or removal, and the possibility to titrate or re-titrate the doses quickly. Disadvantages include a limited longevity, risk of infections, catheter disconnections, and interference with patient mobility. An epidural catheter can easily be used for this purpose, but the use is limited by many technical and mechanical factors [13]. The choice of external or totally implanted delivery systems is based on different clinical considerations. The use of an externalized tunneled intrathecal catheter seems to not be associated with high rates of complications and is easier to use in debilitated patients late in the course of their disease. In comparison with the epidural route, the intrathecal route of administration has a lower incidence of catheter occlusion, lower malfunctioning rate, lower dose requirements, and more effective pain control.
How has ziconotide impacted non-cancer pain management?
Published in Expert Opinion on Pharmacotherapy, 2020
Timothy Deer, Jonathan M. Hagedorn
The use of ziconotide should be avoided in certain circumstances. In patients with a history of severe depression, suicidal ideation, or other psychiatric issues, a careful assessment by a psychological health professional should be obtained prior to drug initiation. A history of psychosis is a contraindication to using ziconotide [5]. Patients with an allergy to ziconotide or the IDT components are not candidates for this therapy. Additionally, the use of ziconotide is not recommended for children or adolescents [5]. Intrathecal therapy, in general, should be avoided in patients with an infection at the surgical site, uncontrolled bleeding diathesis, and spinal canal obstruction with impairment of cerebrospinal fluid circulation.