Intrathecal Bolus Trials of Ziconotide for CancerRelated Pain

Intrathecal Bolus Trials of Ziconotide for Cancer-Related Pain Mitchell Engle M. D. , Ph. D. Obinna Uzodinma, M. D. Brian Bruel, M. D. , M. B. A MD Anderson Cancer Center Houston, TX

Disclosures • ME – None • OU – None • BB – Consultant for Jazz Pharmaceuticals – Consultant for Medtronic

Ziconotide • Synthetic selective N-type Calcium Channel blocker • Problem: Poor pain control in cancer patients despite high dose opioid and adjuvant medications • Objective: Demonstrate that single shot intrathecal trials of ziconotide effectively reduce cancer related pain

Study Design • Retrospective chart review • Three year time period (2009 -2012) • Single shot bolus trials of ziconotide – Both mono- and combination trials • Pre-trial and 24 hr post-procedure numeric pain scores • Successful trial: > 30% numeric pain score reduction • Etiology of pain was tumor or cancer related treatments

Demographic Data • 40 individual patients – 44 independent trials Tumor Related 27 Treatment Related Other 14 3

40 Patients 30 Successful Trials (75%) 10 Failed Trials (25%) 1 Successful Retrial 3 Failed Retrials

Ziconotide Doses Mean (mcg) 2. 6 N 40 2. 5 30 2. 7 10

Combination Effects +Bupivacaine Ziconotide alone +Bupivacaine Zicono (mcg) Bupiv (mg) N Failed Trials Ziconotide alone Successful Trials 2. 8 2. 5 2. 8 2. 6 2. 2 12 16 1. 8 5 5

Dose Distribution

Diagnoses of Successful Trials Metastatic Disease 10 Metastasis to Spine 10 3 Post-laminectomy Pain 2 Locally Advanced Disease CIPN 1 Compression Fractures 1 Other 3

Conclusions • Single shot intrathecal ziconotide produces robust analgesia in cancer pain patients • The average dose of ziconotide for successful trials was approximately 2. 5 mcg • Bupivacaine did not appear to produce an additive or synergistic effect for ziconotide • Ziconotide successfully produced analgesia in patients with metastatic cancer pain, chronic post-surgical pain, and CIPN.