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EMERGING TREATMENT AND DIAGNOSIS | WEBSTER & FAKATA
skeletal muscle, was common in 40% of patients participating
mostly in open-label studies. Elevated CK-MM usually
occurred within the first 2 months of therapy. Other isoenzymes
were rarely affected. Of all patients studied in clinical
trials, there was one case of symptomatic myopathy and two
acute renal failures associated with rhabdomyolysis and
extreme CK elevation (17, 000-27,000 IU/L) (12).
A baseline CK should be obtained with another CK at
2 months, and every 6 months thereafter. CKs should be
obtained if the patient is exhibiting any new neuromuscular
symptoms.
Conclusion
ZICONOTIDE MAY BE MOST EFFECTIVE in reducing pain and
preventing central sensitization by its mechanism of action.
As a result, it may be useful in many patients with CRPS.
Ziconotide will likely not be first-line therapy for CRPS
but will have a role when less invasive therapies have been
exhausted and the pain becomes chronic and severe enough to
warrant an IT pump. Some clinicians are discussing their success
treating CRPS through an earlier utilization of ziconotide
by external catheter. However, prolonged use of external
catheters increases the risk of meningitis. Immediate pain relief
should not be expected with the recommended slow titration.
Treatment with ziconotide will need to be based on the
individual’s response. Ziconotide has the potential of becoming
an important analgesic in our armamentarium to treat CRPS.
REFERENCES
1. Ziconotide: Use in Reflex Sympathetic Dystrophy, PRI031_
Use_in_Reflex_Sympathetic Dystrophy 03 Ref Number:1-6462160, Elan
Pharmaceutical Inc.
2. Miljanich GP. Ziconotide: Neuronal Calcium Channel Blocker for Treating
Severe Chronic Pain. Current Medicinal Chemistry, 2004. 11: 3029-3040.
3. Ribbers, GM, Geurts AC, Stam HJ, Mulder T. Pharmacologic Treatment of
Complex Regional Pain Syndrome I: A Conceptual Framework. Archives of
Physical Medicine and Rehabilitation 2003; 84: 141-146.
4. Harden RN. Chronic Neuropathic Pain. The Neurologist 2005 11(2): 111-
122.
5. Miljanich GP. Ziconotide: Neuronal Calcium Channel Blocker for Treating
Severe Chronic Pain. Current Medicinal Chemistry, 2004. 11: 3029-3040.
6. Hassenbusch SJ , Portenoy RK, Cousins M et al. Polyanalgesic Consensus
Conference 2003: An Update on the Management of Pain by Intraspinal
Drug Delivery-Report of an Expert Panel. Journal of Pain and Symptom
Management. 2004, 27(6):540-563.
7. Shields D, Montenegro R . The Chemical Stability of Admixtures Combining
Ziconotide and Hydromorphone during Simulated Intrathecal Administration.
(Abstract) Neuromodulation 2005 Vol 8(in press).
8. Shields D, Montenegro R, Ragusa M. The Chemical Stability of Admixtures
Combining Ziconotide and Morphine Sulfate during Simulated
Intrathecal Administration. (Abstract) Neuromodulation 2005. Vol 8(in
press).
9. Shields D, Montenegro R, The Chemical Stability of Admixtures Combining
Ziconotide and Clonidine during Simulated Intrathecal Administration.
(Abstract) Neuromodulation 2005. Vol 8(in press).
10. Shields D, Montenegro R, Ragusa M . The Chemical Stability of Admixtures
Combining Ziconotide and Bupivacaine during Simulated Intrathecal
Administration. (Abstract). Neuromodulation 2005 Vol 8(in press).
11. Webster LR, Fakata KL, Ziconotide for Severe Chronic Pain. Practical Pain
Management May 2005.
12. Prialt (ziconotide intrathecal infusion) prescribing information. Elan
Pharmceutical Inc. 2/2005.
LYNN R. WEBSTER, MD,
is Medical Director, CEO,
Lifetree Pain Clinic,
Salt Lake City, Utah
KERI L. FAKATA, PHARMD,
Lifetree Research and Pain
Clinic, Clinical/Research
Pain Management Pharmacist,
Salt Lake City, UT
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