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CME Disclosures 2 Will discuss off label and investigational indications for medications and devices All activities are reviewed by Albert Einstein Healthcare Network’s conflict of interest committee Honoraria are paid directly to PMR department
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Spasticity Update
Michael Saulino, MD PhD Physiatrist MossRehab Assistant Professor Physical Medicine and Rehabilitation Thomas Jefferson University Hospital
CME Disclosures 1
• Speaker’s bureau for Jazz Pharmaceuticals• Speaker’s bureau and clinical investigator for
Medtronic, Inc• Speaker’s bureau for Ipsen• Consultant for SPR therapeutics and
Myoscience
CME Disclosures 2
• Will discuss off label and investigational indications for medications and devices
• All activities are reviewed by Albert Einstein Healthcare Network’s conflict of interest committee
• Honoraria are paid directly to PMR department
Surgery
ITB
NeurolyticBlockade
OralMedications
PhysicalMeasures
Removal ofNoxious Stimuli
Synergistic Model of Spasticity Management
Surgery
ITB
NeurolyticBlockade
OralMedications
PhysicalMeasures
Removal ofNoxious Stimuli
Synergistic Model of Spasticity Management
Oral Pharmacological Options • Baclofen (Lioresal) *• Diazepam (Valium)• Neurontin (Gabapentin)• Clonidine (Catapress)• Tizadine (Zanaflex) *• Dantrolene (Dantrium) *
* FDA approved for spasticity
Baclofen (Lioresal)• Racemic GABA B receptor agonist• Both pre- and post-synaptic activity resulting in inhibition
of both monosynaptic and polysynaptic reflexes at the spinal level
• R enatomier considered to the 5-6 times more potent
Baclofen Several pharmacologic limitations:
Only absorbed in the upper small intestineSaturable active transport mechanismShort half life (3-4 hrs)Requires frequent administrations for effectivenessSustained release formulation unachievable
Arbaclofen Placarbil• Improved absorption of R enatomoer by disguising it
as a nutrient which uses an active transport mechanism• Compared with immediate-release baclofen,
arbaclofen has a flatter pharmacokinetic profile and more sustained plasma levels allowing less frequent dosing
Arbaclofen SCI Trial• Double-blind, placebo-controlled crossover study • 37 SCI patients >1 year after injury, Ashworth > 2 after washout• Arbaclofen 10, 20, or 30 mg BID or placebo • Primary end point: Difference in Ashworth scale
Arbaclofen SCI Trial
Arbaclofen SCI Trial
Arbaclofen SCI Trial
ArbaclofenInitial SCI trial suggests efficacy of BID dosing and
improved tolerability compared to immediate release racemic oral baclofen
Ongoing trial in multiple sclerosis• Currently ongoing at 35 sites in US • Randomizing 200 patients • 4 treatments: placebo, 15 mg, 30 mg, or 40 mg
twice daily over 8 weeks • Followed by an on open label study
Botulinum Neurotoxin
• The most potent neurotoxin known • Derived from Clostridium botulinum • Variations in the polypeptide sequence produce
different serotypes of toxin, referred to as types A, B, C1, D, E, F and G
• The different serotypes can evoke different immune responses; for each serotype, multiple packaging and formulation options exist, adding to the variability
Mechanism of action
Mechanism of action
Toxin Formulations Available in US
• Only Onabotulinumtoxin A (Botox) is approved for adult upper extremity spasticity
Toxin Dilution Reasonable Max Dosing
Onabotulinumtoxin A 25-100 units/ml 400 U / limb 600 U / session
Abobotulinumtoxin A 200-500 units/ml 1500 U / limb 2000 U / session
Incobotulinumtoxin A 25-100 units/ml 400 U/ limb 500 U / session
Rimabotulinumtoxin B 5000 units/ml 10,000 U / limb 20.000 U / session
Intrathecal baclofen therapy
• Traditionally, effects of ITB have been related to two factors:– Catheter tip location– Dosage administered
• Emerging data suggests that drug concentration / volume administered / flow rate can play a role in therapeutic effects.
Visual example of volume effects
0.1 mL1 mL test dose 0.048 mL
Concentration effects
• Bernards and colleagues have demonstrated enhanced distribution of ITB away from the catheter tip at lower concentrations in an animal models
• Same group also demonstrated logarimithic relationship between ITB concentration and baricity
Agent
• Chiodo and colleaues reported improved spasticity control in a small case series with lower ITB concentration
• Stokic and Yablon demonstrated enhanced electrophysiological suppression of spasticity at lower ITB concentrations
• van des Plas and colleagues failed to detect a difference in CRPS-dystonia reduction with differential flow rate and fixed ITB dosing
Agents
• Intrathecal Lioresal – FDA approved – Medtronic / Novartis
• Intrathecal Gablofen – FDA approved – CNS therapeutics
• Compounded baclofen – not FDA approved – state regulated, compounding pharmacies
Agent
• 2 published articles (Moberg-Wolff and Farid et al) describe considerable variability in compounded baclofen compared to branded intrathecal Lioresal
• Handful of conference abstracts describing adverse effects with compounded baclofen products