Intrathecal combination of ziconotide and morphine for refractory malignant pain: A rapidly acting and effective choice

PainAlicino I et al. | November 17, 2011

An intrathecal (IT) combination of low doses of ziconotide and morphine allows safe and rapid control of oral opioid–refractory malignant pain.


  • Patients with malignant pain refractory to high oral opioids doses with a mean visual analogue scale of pain intensity (VASPI) score of 70mm were enrolled.
  • An IT combination therapy was administered: Ziconotide was started at a dose of 2.4μg/day, followed by increases of 1.2 μg/day at intervals of at least 7days, and an initial IT daily dose of morphine was calculated based on its oral daily dose.
  • Percentage change in VASPI scores from baseline was calculated at 2days, at 7days, and weekly until the first 28days.
  • The mean percentage change of VASPI score from baseline was used for efficacy assessment.
  • Safety was monitored based on adverse events and routine laboratory values.
  • Twenty patients were enrolled, with a mean daily VASPI score at rest of 90±7.


  • All had a disseminated cancer with bone metastases involving the spine.
  • The percentage changes in VASPI mean scores from baseline to 2days, 7days, and 28days were 39±13% (95% confidence interval [CI]=13.61–64.49, P<.001), 51±12% (95% CI=27.56–74.56, P<.001), and 62±13% (95% CI=36.03–87.89%, P<.001), respectively.
  • Four patients experienced mild adverse events related to the study drugs.

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