Ziconotide-induced psychosis: A case report and literature review

Abstract

Ziconotide is an intrathecally administered medication indicated for the treatment of severe chronic pain in patients who are intolerant of or refractory to other treatment options. A black box warning is included in the packaging and states ziconotide is contraindicated in patients with a preexisting history of psychosis. Patients taking ziconotide should be monitored for evidence of cognitive impairment, hallucinations, or changes in mood, and ziconotide should be discontinued if neurological or psychiatric signs and symptoms appear. We present a case of a 49-year-old white male with no previous neuropsychiatric history who received ziconotide for several years before he developed command auditory hallucinations within 24 hours of a dose increase. Upon admission to the emergency room, the patient's pain management physician was contacted and the ziconotide dose was decreased and eventually discontinued. Because of a continuation of symptoms, the patient was transferred from the emergency room to an acute care psychiatric hospital where he was started on risperidone 1 mg orally at bedtime. At discharge, the patient was noted to be in good behavioral control without any hallucinations. The patient was encouraged to follow up with his pain management physician to determine if ziconotide should be reconsidered.

A Benefit/Risk Assessment of Intrathecal Ziconotide in Chronic Pain: A Narrative Review

“…Other reports also sustain these findings [ 59 , 60 ]. Therefore, a comprehensive psychiatric evaluation is recommended before starting and during Ziconotide treatment [ 61 ].…”

“…The most important side effects seem to be psychiatric disorders that can worsen when already present [ 61 ] and the elevation of CK serum values, which can lead to consequences from a metabolic viewpoint [ 62 ]. Since the adverse consequences of IT Ziconotide infusion do not exceed the benefits in patients with chronic drug-resistant pain compared to oral or intramuscular–venous administration, the benefit/risk assessment is favorable.…”

Ziconotide-Induced Oro-lingual Dyskinesia: 3 Cases

“…The drug is delivered via an intrathecal infusion pump. Side effects are dose related and ZCN labelling features a black box warning for severe neuropsychiatric and cognitive adverse events, which have been reported even in patients with no prior history of psychiatric disease [ 1 2 3 4 5 6 ]. Although “dyskinesia” is mentioned in a clinical trial report for the drug, almost no literature exists on ZCN-induced movement disorders [ 7 ].…”