title: Acute rhabdomyolysis in a patient with long-term exposure to intrathecal ziconotide: a case report.
abstract: BACKGROUND
  Ziconotide is an intrathecally administered nonopioid analgesic for the treatment of severe chronic pain. Previous reports have noted rhabdomyolysis in patients receiving ziconotide during the initial single-shot trial or due to concurrent medical problems. We present a case of an acute rhabdomyolysis following an intrathecal bolus injection of ziconotide on a patient who had long-term exposure to the drug.
  
  
  METHODS
  The patient suffered from chronic neuropathic pain with diagnosis of failed back surgery syndrome and received intrathecal ziconotide for 2 years. Moderate side effects resulting from dose escalation led to a discontinuation of the drug. The pump medication was changed to morphine, which failed to provide adequate analgesia even with dose titration. A single intrathecal bolus of ziconotide, as an adjunctive therapy, resulted in good pain control. Two months later, the patient received a second ziconotide injection. Sixteen hours after the injection, she presented to local emergency center with nausea, vomiting, diarrhea, and myalgia. She had significantly increased CK levels and was admitted for intravenous hydration and close observation. Her serum CK level peaked at 4940 IU/L. The patient was discharged on hospital day 3 with a CK level of 808 IU/L. Her symptoms resolved without renal impairment.
  
  
  CONCLUSIONS
  The clinical scenario described is a case of acute rhabdomyolysis from an intrathecal bolus injection of ziconotide in a patient with prior long-term exposure to the drug. The decrease in CK levels coincided well with the average half-life of ziconotide; however, the rhabdomyolysis may have been potentiated by hypokalemia.
authors.affiliation: Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, U.S.A.
authors.forename: Christian
authors.initials: C
authors.lastname: Horazeck
authors.forename: Albert S
authors.initials: AS
authors.lastname: Huh
authors.forename: Billy K
authors.initials: BK
authors.lastname: Huh
mesh_terms: D000368:Aged; D018712:Analgesics, Non-Narcotic / Q000009:adverse effects*; D000701:Analgesics, Opioid / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D055111:Failed Back Surgery Syndrome / Q000150:complications / Q000188:drug therapy*; D005260:Female; D006801:Humans; D007278:Injections, Spinal; D009020:Morphine / Q000627:therapeutic use; D009437:Neuralgia / Q000188:drug therapy* / Q000209:etiology; D059408:Pain Management; D010147:Pain Measurement; D012206:Rhabdomyolysis / Q000139:chemically induced*; D020960:omega-Conotoxins / Q000009:adverse effects*
chemical_list: D018712:Analgesics, Non-Narcotic; D000701:Analgesics, Opioid; D020960:omega-Conotoxins; D009020:Morphine; C078452:ziconotide
keywords: Ziconotide; failed back surgery syndrome; hypokalemia; intrathecal drug delivery; rhabdomyolysis; safety