EMERGENCY PROCEDURES Intrathecal Baclofen Therapy with Lioresal Intrathecal (baclofen injection)
Clinicians must be vigilant for any indication of an adverse event during all phases of ITB TherapySM (intrathecal baclofen therapy). Refer to the Lioresal® Intrathecal (baclofen injection) prescribing information for a complete listing of potential drug-related adverse events.
Patients vary in their sensitivity to Lioresal Intrathecal. The most commonly observed side effects, which are typically managed through dose titration or adjuvant medications, are:
Clinicians must always be alert to the symptoms of overdose, especially during the screening test, post-implant dose titration, and whenever ITB Therapy has been interrupted and reintroduced. Early symptoms of overdose include:
If untreated, overdose can progress and produce the following:
To safeguard against overdose:
An emergency procedure and treatment protocol for overdose is available. In the United States, emergency technical support is available 24 hours/day for clinicians managing patients with Medtronic SynchroMed™ infusion systems: 800-707-0933. In other world areas, contact your Medtronic representative.
Withdrawal of intrathecal baclofen presents with a wide spectrum of severity and symptoms. It is important to act quickly if withdrawal is suspected, as symptoms can quickly escalate. Treat suspected baclofen withdrawal as a medical emergency.
Symptoms of advanced withdrawal include, but may not be limited to:
In rare instances, if withdrawal is left untreated, rhabdomyolysis, multiple organ-system failure, and/or death may result.
It is important to note that an advanced case of intrathecal baclofen withdrawal may resemble the following conditions:
All patients receiving intrathecal baclofen are potentially at risk of withdrawal. The primary cause of intrathecal baclofen withdrawal is abrupt discontinuation of drug delivery. To safeguard against withdrawal:
Rapid, accurate diagnosis and treatment of intrathecal baclofen withdrawal in an emergency department or intensive-care setting are important to prevent potentially life-threatening effects on the central nervous system and systemically.
The suggested treatment for intrathecal baclofen withdrawal is the restoration of intrathecal baclofen at or near the same dosage as before therapy was interrupted. However, if restoration of intrathecal delivery is delayed, treatment with GABA-ergic agonistic drugs such as oral or enteral baclofen, or oral, enteral, or intravenous benzodiazepines may prevent potentially fatal sequelae. Oral or enteral baclofen alone should not be relied upon to halt the progression of intrathecal baclofen withdrawal.
An emergency procedure and treatment protocol for withdrawal is available. In the United States, emergency technical support is available 24 hours/day for clinicians managing patients with Medtronic SynchroMed infusion systems: 800-707-0933. In other world areas, contact your Medtronic representative.
Product technical manuals and the appropriate drug labeling must be reviewed prior to use for detailed disclosure.
US: Chronic intraspinal (epidural and intrathecal) infusion of preservative-free morphine sulfate sterile solution in the treatment of chronic intractable pain, chronic intrathecal infusion of preservative-free ziconotide sterile solution for the management of severe chronic pain, and chronic intrathecal infusion of Lioresal® Intrathecal (baclofen injection) for the management of severe spasticity; chronic intravascular infusion of floxuridine (FUDR) or methotrexate for the treatment of primary or metastatic cancer. Outside of US: Chronic infusion of drugs or fluids tested as compatible and listed in the product labeling.
Infection; implant depth greater than 2.5 cm below skin; insufficient body size; spinal anomalies; drugs with preservatives, drug contraindications, drug formulations with pH ≤3, use of catheter access port (CAP) kit for refills or of refill kit for catheter access, blood sampling through CAP in vascular applications, use of Personal Therapy Manager to administer opioid to opioid-naïve patients or to administer ziconotide.
Non-indicated formulations may contain neurotoxic preservatives, antimicrobials, or antioxidants, or may be incompatible with and damage the system. Failure to comply with all product instructions, including use of drugs or fluids not indicated for use with system, or of questionable sterility or quality, or use of non-Medtronic components or inappropriate kits, can result in improper use, technical errors, increased risks to patient, tissue damage, damage to the system requiring revision or replacement, and/or change in therapy, and may result in additional surgical procedures, a return of underlying symptoms, and/or a clinically significant or fatal drug under- or overdose. Refer to appropriate drug labeling for indications, contraindications, warnings, precautions, dosage and administration, screening procedures and underdose and overdose symptoms and methods of management. Physicians must be familiar with the drug stability information in the product technical manuals and must understand the dose relationship to drug concentration and pump flow rate before prescribing pump infusion. Implantation and ongoing system management must be performed by individuals trained in the operation and handling of the infusion system. An inflammatory mass that can result in serious neurological impairment, including paralysis, may occur at the tip of the implanted catheter. Clinicians should monitor patients on intraspinal therapy carefully for any new neurological signs or symptoms, change in underlying symptoms, or need for rapid dose escalation.
Inform patients of the signs and symptoms of drug under- or overdose, appropriate drug warnings and precautions regarding drug interactions, potential side effects, and signs and symptoms that require medical attention, including prodromal signs and symptoms of inflammatory mass. If it is suspected or known that all or part of the drug was injected into the pocket during the refill procedure, monitor the patient closely for signs and symptoms of overdose in an appropriate facility for a sufficient amount of time or until the symptoms have resolved. Failure to recognize signs and symptoms and seek appropriate medical intervention can result in serious injury or death. Instruct patients to notify their healthcare professionals of the implanted pump before medical tests/procedures, to return for refills at prescribed times, to carry their Medtronic device identification card, to avoid manipulating the pump through the skin, to consult with their clinician if the pump alarms and before traveling or engaging in activities that can stress the infusion system or involve pressure or temperature changes. Strong sources of electromagnetic interference (EMI), such as short wave (RF) diathermy and MRI, can negatively interact with the pump and cause heating of the implanted pump, system damage, or changes in pump operation or flow rate, that can result in patient injury from tissue heating, additional surgical procedures, a return of underlying symptoms, and/or a clinically significant or fatal drug underdose or overdose. Avoid using shortwave (RF) diathermy within 30 cm of the pump or catheter. Effects of other types of diathermy (microwave, ultrasonic, etc.) on the pump are unknown. Drug infusion is suspended during MRI; for patients who can not safely tolerate suspension, use alternative drug delivery method during MRI. Patients receiving intrathecal baclofen therapy are at higher risk for adverse events, as baclofen withdrawal can lead to a life threatening condition if not treated promptly and effectively. Confirm pump status before and after MRI. Reference product labeling for information on sources of EMI, effects on patient and system, and steps to reduce risks from EMI.
Monitor patients after device or catheter replacement for signs of underdose/overdose. Infuse preservative-free (intraspinal) saline or, for vascular applications, infuse heparinized solutions therapy at minimum flow rate if therapy is discontinued for an extended period of time to avoid system damage. EMI may interfere with programmer telemetry during pump programming sessions. EMI from the SynchroMed programmer may interfere with other active implanted devices (e.g., pacemaker, defibrillator, neurostimulator).
Include, but are not limited to, spinal/vascular procedure risks; infection; bleeding; tissue damage, damage to the system or loss of, or change in, therapy that may result in additional surgical procedures, a return of underlying symptoms, and/or a clinically significant or fatal drug underdose or overdose, due to end of device service life, failure of the catheter, pump or other system component, pump inversion, technical/programming errors, injection into the pocket or subcutaneous tissue or improper use, including use of non-indicated formulations and/or not using drugs or system in accordance with labeling; pocket seroma, hematoma, erosion, infection; post-lumbar puncture (spinal headache); CSF leak and rare central nervous system pressure-related problems; hygroma; radiculitis; arachnoiditis; spinal cord bleeding/damage; meningitis; neurological impairment (including paralysis) due to inflammatory mass; potential serious adverse effects from catheter fragments in intrathecal space, including potential to compromise antibiotic effectiveness for CSF infection; anesthesia complications; body rejection phenomena; local and systemic drug toxicity and related side effects; potential serious adverse effects from catheter placement in intravascular applications.
Lioresal® is a registered trademark of Saol
USA Rx Only
Important Safety Information
Indications and Usage
Select Warnings and Precautions
Common Adverse Reactions
Serious Adverse Reactions
Use in Specific Populations
For more information, including BOX WARNING, refer to Lioresal® Intrathecal (baclofen injection) prescribing information.