Long-term spinal analgesic delivery: A review of the preclinical and clinical literature

Wallace, Mark; Yaksh, Tony L.

doi:10.1053/rapm.2000.0250117

Cited by 70 publications

(75 citation statements)

References 288 publications

(282 reference statements)

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“…It is a muscle relaxant with its prime site of action in the spinal cord, where it binds to the inhibitory GABA b receptor. 1 The uptake of baclofen across the blood-brain barrier is limited, so high oral doses are needed to achieve a therapeutic effect, causing side effects such as muscle weakness and drowsiness. 2 Baclofen can be infused intrathecally using a lumbar drain connected to a subcutaneously located programmable pump.…”

Section: Introductionmentioning

confidence: 99%

“…First suggested by Penn and Kroin in 1984, ITB therapy has proven to be safe and successful in treating severe spasticity. [3][4][5] The subcutaneous pump allows three different infusion modes: (1) simple continuous infusion at a steady rate throughout the day, (2) complex continuous infusion using 4-6 hourly blocks consisting of different doses and (3) a pulsatile bolus mode, delivering a drug bolus at a fixed interval. The development of tolerance is one of the major concerns of ITB therapy.…”

Section: Introductionmentioning

confidence: 99%

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The incidence and management of tolerance in intrathecal baclofen therapy

et al. 2009

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Study design: Retrospective study. Objectives: To study the incidence and management of tolerance in patients treated with intrathecal baclofen (ITB) therapy. Setting: Department of neurology and neurosurgery, University Medical Center Groningen, The Netherlands. Methods: Medical records of all patients who had received an implantable ITB pump at our clinic during 1991-2005 were reviewed. Results: A total of 37 patients (representing 116 pump years) were included. Mean follow-up time was 38 months (range 3-120 months). Baclofen dose increased in the first 18 months after implantation (Po0.05), and then stabilized around a mean dose of 350 mg per day. Eight patients (22%) developed tolerance, defined as a dose increase of 4100 mg per year. No predictive factors for development of tolerance could be determined. Three different treatment regimens for tolerant patients were analyzed. Altering the infusion mode from simple to complex continuous (n ¼ 6) had no effect on the development of tolerance. Pulsatile bolus infusion (n ¼ 1) and a drug holiday (n ¼ 2) were both effective in reducing the daily baclofen dose. Patients who needed surgical revision of the pump system because of mechanical failures (n ¼ 11) showed a significant dose decrease during the first month after revision, indicating that the preoperative dose increase most likely had been caused by the pump failure. Pumprelated complications occurred once per 10.5 years of ITB treatment. Drug-related side effects had an annual risk of 13.8%. The reported events were mostly mild. Conclusions: ITB therapy is effective and safe, also in the long term and causes tolerance in only 22% of the treated patients.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

The incidence and management of tolerance in intrathecal baclofen therapy

et al. 2009

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“…The number of receptors decreases after repeated drug infusion, causing the loss of efficacy of baclofen. 8,10 Other reports indicate the interaction between GABAb receptor and opioid receptor systems within the spinal cord. 11 …”

Section: Introductionmentioning

confidence: 99%

Efficacy of intrathecal morphine in the treatment of baclofen tolerance in a patient on intrathecal baclofen therapy (ITB)

et al. 2004

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Study design: Case report. Objectives: A case report of tolerance to intrathecal baclofen therapy (ITB) treated with intrathecal morphine ('baclofen holiday'). Setting: Institut Guttmann, Neurorehabilitation Hospital of Barcelona, Spain. Case Report: A 30-year-old female patient is described with incomplete paraplegia below T6 on the left side and below T8 on the right side, ASIA B, caused by trauma occurring 12 years previously, in whom an intrathecal system had been implanted for baclofen infusion 10 years ago. The patient showed tolerance to baclofen therapy and was treated with intrathecal morphine infusion for 2 weeks. Baclofen infusion resulted in adequate control of spasticity.

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“…In the case of failure to achieve adequate pain relief with ziconotide or in the case of side effects related to the use of ziconotide, the experts recommend increasing the dose of intrathecal opioid. However with the use of an intrathecal combination therapy, is mandatory to consider drug stability as mixing drug with low stabilities requires a more frequent pump refill: morphine apparently can interfere with ziconotide stability [12,13].…”

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confidence: 99%