Intrathecal Drug Delivery By Jennifer Gray Specialist Clinical Pharmacist Neurosurgery, Pain and Palliative Care Ninewells Hospital 17/04/18

Background Intrathecal Drug Delivery is a method of giving medication directly into the spinal cord It’s an option when most other treatment options have failed As the medications are delivered directly into the spinal cord, symptoms can be controlled with much smaller doses than would be required orally Side effects are reduced It is an unlicensed product As intrathecal bipasses the path that oral medication takes through the body Roughly 1/300 the amount of oral medication reqd Medications are released slowly over a period of time

Medications Commonly Used Hydromorphone – Is a potent opioid with increasing intraspinal “off-label” use to treat cancer and non-malignant pain. Side effects are less common compared to morphine Clonidine – Is an a2 Agonist that enhances the analgesic affect of the opioid. It is often effective for neuropathic pain. Side effects include hypotension and sedation Levobupivicaine /Bupivicaine – Is a sodium channel blocker used as an anaesthetic. Side effects include motor weakness and urinary retention Medications Commonly Used Commonly used for palliative patients May also have heard of baclofen pumps

The Team Palliative Care Consultant(s) Pain Consultant(s) Neurosurgeon Palliative Pharmacist Palliative Technician Aseptic Pharmacist Who is involved in the process

Education and Training Standard Operating Procedure – Unlicensed Opioid Intrathecal Injection Must comply with “ The Safe and Secure Handling of Medicines Policy” and “The Controlled Drug Policy”

The Prescription Prescriber will complete a prescription and request form (Handout 1) Pharmacist verifies this, checking calculations and strengths The Prescription is then given to the pharmacy office for them to get in contact with ITH Pharma with regards to formulation and delivery date NEED TO DECIDE IF THE PATIENT IS AN APPROPRIATE CANDIDIATE

Ordering Order product from ITH Pharma (company that specialises in the provision of aseptic compounding services for all therapy areas) Manufacturing and delivery is roughly a one week process They request a copy of the prescription Product is labelled for the patient specifically with name and CHI The cost is around £400 per syringe Monday – Friday Service (no orders to ITH Pharma out with this time)

Storage Product kept in quarantine in dispensary CD vault “ intrathecal in quarantine” The product is entered into the intrathecal register by the palliative technician The cassette or syringe is pre-labelled The product will be packed and transported separately from treatments for administration by other routes The intrathecal should be collected immediately before the planned administration The package with clearly state “for intrathecal use only” Expiry is a month from ITH Pharma manufacturer , however the pain consultant extends the time Technician will alos release the product along with a member of the aseptic unit who visualises the product for contamination/ particles

Thank You Any Questions