Ziconotide is a selective and potent blocker of N-type voltage-gated
calcium channels. It was approved by the Food and Drug Administration in 2004 and by the European Medicines Agency in 2005 for the treatment of severe
chronic pain in patients needing intrathecal
analgesia (ITA). The aim of this paper is to provide a practitioner-oriented, educational, narrative, up-to-date review on the use of
ziconotide in clinical
pain medicine. Of special concern regarding safety is the partial incongruity between dosing statements in the Summary of Product Characteristics and novel low-dosage, slow uptitration recommendations. Even though
ziconotide has obvious advantages compared to
opioids,
pain practitioners pondering the use of
ziconotide nonetheless have to balance its proved potential
analgesic effect against its neurological side effects, with special consideration being given to dosing and neuropsychiatric dangers. Using a seesaw analogy, the paper discusses what factors
pain physicians should weigh in when considering
ziconotide as ITA
drug, the non-
opioid advantages of
ziconotide being counterbalanced by its potential psychiatric side effects.
Ziconotide is an important part of the armamentarium of modern interventional
pain medicine. If ITA is deemed necessary,
ziconotide is a rational alternative, at least in chronic (neuropathic) non-
cancer pain. However, in many European countries,
ziconotide treatment is only available in a few (if any) centres. The safety profile of
ziconotide is not fundamentally more worrying than that of
opioids or
cannabinoids; it is just different. This paper provides a concise, up-to-date and clinically-oriented summary of the use of
ziconotide in clinical practice, not least concerning safety and dosage issues.