Title : Healthy and successful pregnancy while receiving intrathecal ziconotide for arachnoiditis-related chronic pain
Abstract:
Arachnoiditis-associated pain is notoriously treatment-resistant and may persist for many years. Despite treatment with varying combinations of drugs, patients are often left with a high pain burden. Many analgesics and medications used to treat such pain are contraindicated for use during pregnancy.
The use of high dose or prolonged oral, topical or intrathecal opioids may result in abnormalities of the hypothalamic-pituitarygonadal axis in some patients. There is extensive literature documenting these adverse effects and the need for supplemental or hormone replacement therapy to counteract these effects. We have treated several young chronic pain patients with ziconotide intrathecal monotherapy or combination therapy using ziconotide as the base (primary drug in the programmer) drug with opioids, bupivacaine or baclofen. Ziconotide has been used as a bolus injection without any dangerous adverse effects. The drug does not have any cardiac or pulmonary adverse effects and has been used for bolus trials successfully in the outpatient setting.
A23 year old with arachnoiditis-associated pain (average 7/10, numeric rating scale) received a bolus trial of ziconotide (3- mcg in 1ml over 30 sec) by intrathecal (IT) injection, reducing her pain score to 3/10. She subsequently had a Synchromed II 20 ml IT pump implanted for ziconotide monotherapy infusion. The starting ziconotide dose was 1 mcg/day, which was titrated over 2 months to 2.5 mcg/d. After several miscarraiges she became pregnant and remained on IT Prialt.
A Personal Therapy Manager (PTM) was added, allowing an additional 0.2 mcg ziconotide bolus every eight hours for breakthrough pain (eventually increased to 0.25 mcg every 4 hours). The patient maintained an active lifestyle with a continuous ziconotide dose of 16.4 mcg/day with an average pain score of 4/10. Two years after implantation, the patient became pregnant but miscarried. She became pregnant again one year later while on a stable continuous ziconotide dose of 16.2 mcg/day (reduced to 14.98 mcg/day during pregnancy) with a PTM dose of 0.25 mcg every four hours.
There were no apparent adverse effects related to drug during pregnancy, and she delivered a healthy girl at 38 weeks via elective Caesarian section after prolonged labor. She remains stable on ziconotide 14.98 mcg/day with a PTM dose of 0.25 mcg every 4 hours.
