Use of PTM with Intrathecal Baclofen Pump Results in Better Spasticity Management

Background: Baclofen is the primary medication used for spasticity in MS. It functions as a structural analog GABA and exerts it’s effects by GABA(B) activation. Baclofen can be delivered orally or via Intrathecal Baclofen Therapy (ITB).ITB pump is placed after a successful trial. Baclofen is delivered as a continuous infusion. Patients require frequent adjustments to compensate for disease progression and/or development of tolerance. Some patients require oral Baclofen for intermittent spasms. Repeated visits for infusion adjustments can become a considerable time commitment and financial burden on patients. 

Objectives: Addition of Patient Therapy Manager (PTM) with intrathecal pumps for control of intermittent spasms/pain result in marked reduction of office visits and  improved pain/spasticity .

Methods: Two case reports of patients with diagnosis of MS with permanent intrathecal pump placement who use PTM. The function of the PTM is to deliver a bolus dose when an increase in pain/spasms occurs. There is a lockout feature to prevent excess medication delivery and is managed by the overseeing physician.

Case1:Mr. X is a 58 year old male with a 10+ year history of MS resulting in severe spastic paraplegia. He lives in rural Arkansas and must travel over 2 hours to meet with the physician who manages his intrathecal pump. After taking over this patient’s care and establishing rapport with his spouse, the primary care giver, PTM was added to the basal rate at 15mcg/6 hours prn. No adverse effects reported, dose escalated to 40mcg/6 hours over 3months. Patient stabilized at this dose.  He is currently stable at continuous infusion at 425mcg Baclofen with 40mcg PTM. He reported that intermittent spasticity responded very well with the addition of PTM and led to reduction in office visits.

Case2:Mr. Y is a 48 year old nursing home resident with a 16 year history of MS suffering from severe MS related spastic paraplegia. Intrathecal pump implanted after successful trial. As the disease progressed, spasticity increased and he developed multiple joints pain. It became difficult and painful for him to come for pump refills let alone adjustments. At that time, Hydromorphone added to the Baclofen and PTM was instituted to allow the patient to have tailored pain and spasticity control. The nursing home staff educated regarding PTM use. Pain and spasticity improved after starting PTM and required fewer office visits. He is currently stable at continuous infusion of Baclofen at 249mcg/Hydromorphone 0.24 mg per day with PTM at 20mcg Baclofen/6 hours .

Results: With addition of PTM, 8-9% of the basal dose, patients reported significant improvement in control of pain and spasticity.

Conclusions: Utilization of PTM allows more independence for the patient and/or caregiver by delivering more effective control of debilitating spasticity  with the added benefit of decreased clinic visits and ultimately reduction of financial and logistical burden on patients and their families.