Evaluation of intrathecal drug delivery system for intractable pain in advanced malignancies

Abstract

Pain is prevalent in advanced malignancies; however, some patients cannot get adequate pain relief by conservative routes of analgesic administration or experience serious side effects related to high dose of opioids. For those who have exhausted multimodal conservative analgesic, intrathecal drug delivery is an alternative intervention for truly effective pain management. The objective of this study was to evaluate the clinical efficacy and safety of intrathecal drug delivery system (IDDS) for the treatment of intractable pain in advanced cancer patients.A prospective cohort study was performed between July 2015 and October 2016. Fifty-three patients undergoing intractable cancer-related pain or intolerable drug-related adverse effects were recruited and received IDDS therapy with a patient-controlled intrathecal analgesia pump. The assessment was conducted during admission, in titration period, and followed up monthly to death by scheduled refill visits. Pain numeric rating scale scores, comprehensive toxicity scores, quality of life scores, systemic opioid use (basal and breakthrough dose), intrathecal morphine use (basal and patient-controlled intrathecal analgesia dose), and complications were recorded to evaluate the curative effect and safety.Between baseline and all subsequent follow-ups, statistically significant decreases in pain numeric rating scale scores and comprehensive toxicity scores were verified. A statistical improvement in quality of life scores was found after starting IDDS therapy. Both basal and breakthrough doses of systemic opioid showed a significant decrease during the follow-up period. And there was a modest escalation in the intrathecal morphine dose throughout the duration of study. No infective, device-related, and catheter-related complications were observed.The findings showed that IDDS therapy allowed for rapid and highly effective pain relief with less toxicity in comparison to conservative medications. Patients with advanced malignancies would also benefit from an improvement in the life quality after the procedure. IDDS therapy represented a valuable option for intractable cancer-related pain management.

<p>Intrathecal Morphine Infusion Therapy via a Percutaneous Port for Refractory Cancer Pain in China: An Efficacy, Safety and Cost Utilization Analysis</p>

“…management, which coincides with Zheng's as well as Kim's reports. 16,18 Positions of catheter tips were supposed to be important for the effectiveness of IMITPP, which varied between C7 and L5 in the 43 patients in the present study. As the existence of concentration gradients for many compounds in the CSF after intrathecal infusion was supported by recent magnetic resonance imaging evidences, it seems to be helpful for improving effectiveness to place the catheter tip close to the target receptors of the spinal segment responsible for the pain generator.…”

“…15 Recently, intrathecal morphine infusion therapy via a percutaneous port (IMITPP) has become a widely used approach in some countries for its relatively lower cost. 3,[16][17][18] The efficacy and safety of IMITPP were assessed in this study. A significant decrease of NRS and KPS scores was observed after IMITPP, without serious drug-related adverse events and operative complications.…”

Adult Cancer Pain, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology

“…The intrathecal route of opioid administration should be considered in patients with intolerable sedation, confusion, and/or inadequate pain management with systemic opioid administration. 277 This approach is a valuable tool to improve analgesia for patients who have pain from a variety of anatomic locations (eg, head and neck, upper and lower extremities, trunk). [278][279][280][281] However, due to the risk of catheter migration and infection risk, consider limiting the duration of use to several days.…”

Initiation of Intrathecal Drug Delivery Dramatically Reduces Systemic Opioid Use in Patients With Advanced Cancer

“…One additional study reports a decrease of systemic opioids in a prospective cohort study over a 16‐month period in 53 patients with intractable cancer pain. However, while systemic opioid dose was lowest at the time of discharge, both basal and breakthrough doses were re‐initiated with gradual increases at each of the subsequent follow‐up visits until the time of death (25).…”