2. Disclosures ME – None OU – None BB – Consultant for Jazz Pharmaceuticals – Consultant for Medtronic

3. Ziconotide Synthetic selective N-type Calcium Channel blocker Problem: Poor pain control in cancer patients despite high dose opioid and adjuvant medications Objective: Demonstrate that single shot intrathecal trials of ziconotide effectively reduce cancer related pain

4. Study Design Retrospective chart review Three year time period (2009-2012) Single shot bolus trials of ziconotide – Both mono- and combination trials Pre-trial and 24 hr post-procedure numeric pain scores Successful trial: > 30% numeric pain score reduction Etiology of pain was tumor or cancer related treatments

5. Demographic Data 40 individual patients – 44 independent trials Tumor Related Treatment Related Other 27 14 3

6. 40 Patients 30 Successful Trials (75%) 1 Successful Retrial 10 Failed Trials (25%) 3 Failed Retrials

7. Ziconotide Doses 2.62.52.7Mean (mcg) N403010

8. Combination Effects Zicono (mcg) N Bupiv (mg) Successful Trials Ziconotide alone +Bupivacaine Ziconotide alone +Bupivacaine Failed Trials 2.82.5 2.2 1216 2.82.6 1.8 55

9. Dose Distribution

10. Diagnoses of Successful Trials Metastatic Disease Metastasis to Spine Post-laminectomy Pain Locally Advanced Disease CIPN Compression Fractures Other 10 3 2 1 1 3

11. Conclusions Single shot intrathecal ziconotide produces robust analgesia in cancer pain patients The average dose of ziconotide for successful trials was approximately 2.5 mcg Bupivacaine did not appear to produce an additive or synergistic effect for ziconotide Ziconotide successfully produced analgesia in patients with metastatic cancer pain, chronic post-surgical pain, and CIPN.