Intrathecal Clonidine Pump Failure Causing Acute Withdrawal Syndrome With ‘Stress-Induced’ Cardiomyopathy

Abstract

Clonidine is a central alpha(2)-agonist antihypertensive used widely for opioid/alcohol withdrawal, attention deficit hyperactivity disorder and chronic pain management. We describe a case of clonidine withdrawal causing lifethreatening hypertensive crisis and stress-induced cardiomyopathy. A 47-year-old man with chronic back pain, treated with clonidine for many years via intrathecal pump (550 mcg/24 h), presented following a collapse and complaining of sudden worsening of back pain, severe headache, diaphoresis, nausea and vomiting. A few hours prior to presentation, his subcutaneous pump malfunctioned. On presentation, vital signs included pulse 100 bpm, BP 176/103 mmHg, temperature 37.8°C and O 2 saturation 100 % (room air). Acute clonidine withdrawal with hypertensive crisis was suspected. Intravenous clonidine loading dose and a 50 mcg/h infusion were commenced. Five hours later, severe chest pain, dyspnoea, tachycardia, hypoxia, with BP 180/120 mmHg and pulmonary edema ensued. ECG showed sinus tachycardia with no ST elevation. Repeated intravenous clonidine doses were given (25 mcg every 5-10 min), with ongoing clonidine infusion to control blood pressure. Glyceryl trinitrate infusion, positive pressure ventilation and intravenous benzodiazepines were added. Bedside echocardiogram showed stress-induced cardiomyopathy pattern. Serum troponin-I was markedly elevated. His coronary angiography showed minor irregularities in the major vessels. Over the next 3 days in the ICU, drug infusions were weaned. Discharge was 12 days later on oral clonidine, metoprolol, perindopril, aspirin and oxycodone-SR. Two months later, his echocardiogram was normal. The intrathecal pump was removed. We report a case of stressinduced cardiomyopathy resulting from the sudden cessation of long-term intrathecal clonidine. This was managed by reinstitution of clonidine and targeted organ-specific therapies.

The Polyanalgesic Consensus Conference (PACC): Recommendations for Intrathecal Drug Delivery: Guidance for Improving Safety and Mitigating Risks

“…Clonidine can cause hypotension at lower doses and, paradoxically, hypertension at higher doses, likely through a peripheral vasoconstrictive effect . Clonidine discontinuation can lead to severe withdrawal reaction including life‐threatening hypertensive crisis and stress‐induced cardiomyopathy . Accidental massive injections of clonidine in the subcutaneous tissue during pump refills have been reported in two cases—12,240 mcg in one case and 18,000 mcg in the other .…”

Complications associated with intrathecal drug delivery systems

“…12 Intrathecal clonidine withdrawal, which has also been reported in ITB, 13 manifests in the form of hypertension and leads to rapid onset of a sympathomimetic crisis with associated Takotsubo-type cardiomyopathy. 14 In the absence of obstructive coronary artery lesions, this syndrome, also known as left ventricular apical ballooning syndrome and stress-induced cardiomyopathy, is typically characterised by transient systolic dysfunction of the apical and mid-segments of the left ventricle. Patients often present with symptoms and signs of acute coronary syndrome.…”

Managing Intrathecal Drug Delivery Devices in a Global Pandemic

“…Many of these medications have significant cognitive, respiratory, and mental effects. Many patients have combination of therapies that may cause sudden severe and life-threatening withdrawal reactions such as intrathecal clonidine as with hypertensive crisis and cardiomyopathy (1,2). Abrupt cessation of intrathecal baclofen can result in life-threatening multi-organ failure and death (3).…”