clonidine milind arolker 01.05.2013. outline settings –pain management –other indications levels...
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Clonidine
Milind Arolker
01.05.2013
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Outline
Settings– Pain management– Other indications
Levels of evidence How it works (nice pictures)
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Sources
PCF4 Interventional Pain Control in Cancer
Pain Management. Hester, Sykes, Peat (Eds). OUP (2012)
Other (blind-ish) alleys– search term on websites of major palliative
medicine related journals
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…and the relevance with clonidine?
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So…
RCT type evidence favouring intrathecal drug delivery over systemic drug delivery for cancer pain (opioid-induced side-effects; advantage of greater potency with intraspinal route)
WHO analgesic ladder changes: – Is there a point to weak opioids (step 2)?– “invasive procedures should be considered as an
adjuvant to common analgesic regimens at any stage and should not be regarded as ‘a last resort’” (Eisenberg, IASP clinical update, 2005, Vol XIII, No.5)
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…and clonidine’s place?
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…and clonidine’s place?
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…the evidence base for IT clonidine is even more limited (case reports)…Farquhar-Smith (pg 76)
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2-adrenergic receptor agonist
Licensed– Hypertension– Migraine prophylaxis– Menopausal flushing
• 50 µg po bd• up to 100 µg bd
Unlicensed– Pain poorly
responsive to ED/IT opioid +/- bupivacaine
– spasticity– sialorrhoea– diarrhoea, DM-
related autonomic gastroparesis
– Sweating
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pre-synaptic inhibition!
Peripheral and/or central suppression of sympathetic tone
Pre-synaptic inhibition of nociceptive afferents
Post-synaptic inhibition of spinal cord neurons
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pre-synaptic inhibition!
Peripheral and/or central suppression of sympathetic tone
Pre-synaptic inhibition of nociceptive afferents
Post-synaptic inhibition of spinal cord neurons
IT doses– 30 µg test dose– 150 µg / 24 hrs
CSCI route too: 1.5mg/24hrs (personal communication)
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other effects & side-effects
muscle spasticity (adjunct to baclofen)
induces gut smooth muscle relaxation
2-receptors on enterocytesintestinal fluid and electrolyte reabsorption (improvement in diarrhoea)
Onset: 30-60mins. Half-life: 8-24hrs
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Summary (pico?)
“What’s the evidence for clonidine in pain management (cancer)”– RCT for epidural (cases for IT route)– RCT for IT opioids (+clonidine, probably)
over CMM (pts on 200 mg OME) An adrenergic agonist whose beneficial
therapeutic effects arise from inhibition of sympathetic activity