ziconotide and Granuloma

To better characterize safety profiles associated with the intrathecal (IT) administration of morphine and ziconotide and discuss how they relate to mechanisms of action.. Published data were evaluated to identify potential relationships between safety profiles of IT morphine and IT ziconotide and their mechanisms of action.. Potentially severe and clinically relevant adverse events (AEs) associated with IT morphine include respiratory depression, tolerance, and granuloma formulation, whereas IT ziconotide is associated with neuropsychiatric AEs, such as cognitive impairment, hallucinations, and changes in mood or consciousness, particularly with high doses and rapid titration. AEs associated with these IT therapies may result from spread of the medication out of the IT space into areas of the central and peripheral nervous systems and systemic circulation. AEs that occur usually can be managed and, in some cases, prevented. To mitigate risk, patients' histories should be reviewed to identify potential complicating factors (e.g., obesity or other risk factors for respiratory dysfunction in patients receiving IT morphine; a history of psychosis in patients receiving IT ziconotide). Also, treatment should be initiated at a low dose, titrated slowly, and patients should be closely monitored during treatment.. IT morphine and IT ziconotide are approved by the US Food and Drug Administration for patients who do not respond to less invasive treatments, but the safety profiles of each may make them more or less appropriate for certain patient populations.

Topics: Affect; Analgesics, Non-Narcotic; Analgesics, Opioid; Cognition; Consciousness; Dose-Response Relationship, Drug; Drug Tolerance; Granuloma; Hallucinations; Humans; Injections, Spinal; Morphine; omega-Conotoxins; Pain; Practice Guidelines as Topic; Respiratory Insufficiency

The formation of catheter tip granulomas is an increasingly observed serious complication of intrathecally administered medication. This complication, which is frequently associated with neurological disturbances, has previously been attributed to high dosages and high concentrations of intrathecal morphine. Much less commonly, intrathecal hydromorphone and intrathecal baclofen have also been associated with intrathecal granuloma formation. In the current case, we report a patient who developed her fi rst catheter tip granuloma after 20 months of intrathecal morphine. After surgical granuloma removal and installation of a new catheter, the patient received intrathecal ziconitide for an interim period of six months. Because of a progressive inefficacy, ziconitide was replaced by hydromorphone. One month later, only nine months after the fi rst operative granuloma removal, a new catheter tip granuloma required a further surgical intervention. This case report highlights the potential of intrathecal morphine and hydromorphone to form consecutive inflammatory granulomas within the same patient. To the best of our knowledge, this is the fi rst report of a patient developing two consecutive catheter tip granulomas within nine months.

Topics: Analgesics, Non-Narcotic; Analgesics, Opioid; Catheterization; Female; Granuloma; Humans; Hydromorphone; Injections, Spinal; Laminectomy; Low Back Pain; Magnetic Resonance Imaging; Middle Aged; Morphine; omega-Conotoxins; Orthopedic Procedures; Postoperative Complications; Recurrence; Spinal Diseases