American Society of Regional Anesthesia and Pain Medicine August 2016 - 35
CON
Use of Ziconotide as First Line Intrathecal Therapy?
continued...
effective in managing their pain and not result in intolerable side
effects.
CON #3 - COST
With continued focus and pressure to limit the rise in health care
costs, physicians must also be aware of the cost considerations
of intrathecal therapy. When comparing morphine to ziconotide,
the price differential can be staggering. In our institution, the
average cost of a 20 ml vial of morphine is $30 versus $3,500 for
ziconotide.8,9 If a patient averages around four refills a year, this
results in a five-year cost differential of $69,400. From a purely
economic standpoint, ziconotide makes little sense as first-line
intrathecal therapy.
CONCLUSION
Many factors have led to a palpable paradigm shift away from the
utilization of targeted drug delivery in chronic pain over the past
10 years: the increasing use of spinal cord stimulation, decreasing
reimbursement, introduction of sustained released opioids, and a
lack of exposure in pain fellowships. Despite this, targeted drug
delivery appears primed for resurgence as the focus on controlling
the prescription opioid epidemic increases. Minimal risk of abuse,
drug diversion, and greater prescriber control make targeted drug
delivery systems an attractive alternative to chronic systemic
opiate therapy. It is within this reasoning that a nonopioid analgesic
such as ziconotide is an attractive option for long-term intrathecal
infusion. Ziconotide's side effect profile, narrow therapeutic
window, cost, and efficacy compared to low-dose intrathecal
opioids will keep it from becoming a mainstay in targeted drug
delivery. It should, however, remain a viable treatment option in
select chronic neuropathic pain states in which other treatment
options have failed and the side effect profile is tolerable to the
patient.
REFERENCES
1.
Deer TR, Prager J, Levy R. et al. Polyanalgesic Consensus Conference 2012:
Recommendations for the management of pain by intrathecal (intraspinal)
drug delivery: Report of an interdisciplinary expert panel. Neuromodulation.
2012;15:436-466.
2.
Saulino M, Kim PS, Shaw E. Practical considerations and patient selection
for intrathecal drug delivery in the management of chronic pain. J Pain Res.
2014;7:627-638.
3.
Smith HS, Deer TR. Safety and efficacy of intrathecal ziconotide in the
management of severe chronic pain. Ther Clin Risk Manag. 2009;5:521-534.
4.
Tamargo J, Le Heuzey J-Y, Mabo P. Narrow therapeutic index drugs: a clinical
pharmacological consideration to flecainide. Eur J Clin Pharma. 2015;71:549-
567.
5.
Rauck RL, Wallace MS, Leong MS, et al. Ziconotide 301 Study Group. A
randomized, double-blind, placebo-controlled study of intrathecal ziconotide in
adults with severe chronic pain. J Pain Symptom Manage. 2006;31(5):393-406.
6.
Burton AW, Deer TR, Wallace MS, Rauck RL, Grigsby E. Considerations and
methodology for trialing ziconotide. Pain Physician. 2010;13:23-33.
7.
Bäckryd E, Sörensen J, Gerdle B. Ziconotide trialing by intrathecal bolus
injections: An open-label non-randomized clinical trial in postoperative/
posttraumatic neuropathic pain patients refractory to conventional treatment.
Neuromodulation. 2015;18:404-13.
8.
Dewilde S, Verdian L, Maclaine GD. Cost-effectiveness of ziconotide in
intrathecal pain management for severe chronic pain patients in the UK. Curr
Med Res Opin. 2009;25:2007.
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2016
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