Safety of epidural drugs: a narrative review

Abstract

Introduction: Epidural analgesia is a popular approach to postoperative and labor pain. Neurotoxicity and drug-specific systemic side effects can occur after epidural administration. As an increasing number of epidural drugs are studied and clinically applied, drug efficacy and safety evaluation are crucial. Areas covered: In this narrative review, the authors provide a thorough overview on the safety of the most widely used epidural drugs, focusing on potential neurotoxicity, side effects, and complications in the adult, non-pregnant population. A combined text and MeSH heading search strategy was used to identify relevant publications. Expert opinion: The search for the ideal epidural medication has resulted in a surplus of drug combinations with extensive heterogeneity amongst studies, while the value of investigating these is not always evident. Epidural drugs pose a potential threat of neurotoxicity and other side effects. Consequently, we should pursue safe epidural drug administration to patients and refrain from drugs with minimal proven benefit. Also, studies should compare epidural with systemic application. Because why use a drug epidurally, which can be safely used systemically? Future research should focus on providing solid evidence regarding efficacy of epidural analgesia compared to new and already existing modalities and optimizing presently used medicinal regimens.

Epidural Oxycodone for Acute Pain

“…If a new drug is to be introduced to epidural analgesia, it is a prerequisite that the drug is safe for spinal administration and secondly, more efficacious when given epidurally than i.v. [ 96 ]. Recent clinical studies have shown that epidural oxycodone is substantially more efficacious than the same dose given i.v.…”

“…Neurotoxicity is a concern with any epidural drug and every opioid evaluated so far has shown at least some degree of neurotoxicity. However, very little neurotoxicity is reported in daily clinical practice with epidurally administered opioid doses when conventional doses are utilized [ 96 ]. The neurotoxicity of oxycodone has been studied in one in vitro study.…”

Physiology and Pharmacology of Epidurally Administered Drugs

“…A broad understanding of the pharmacology of those agents is essential for the clinician to utilize them safely and efficiently. Furthermore, it is important to realize that many of those drugs have not been approved for epidural use and are hence used off-label, even when clinically established [93]. Table 2 reveals the list of Food and Drug Administration (FDA)-approved neuraxial drugs.…”

Hypokalemic Periodic Paralysis Masquerading as a Compressive Neuraxial Lesion Following Lumbar Epidural Placement in a Parturient: A Case Report

“…1,2 Several less commonly encountered causes have been previously reported in the literature, including medication-induced neurotoxicity, transverse myelitis, and arachnoiditis. [3][4][5] We present a case of lower extremity paresis occurring several days following lumbar epidural placement in a parturient caused by undiagnosed familial hypokalemic periodic paralysis (HOKPP). Written Health Insurance Portability and Accountability Act (HIPAA) consent was obtained from the patient for publication.…”