CC14
A Quantitative Survey of Practices in Intrathecal Baclofen Therapy
Objectives: To survey standard practices for current ITB therapy.
Methods: A survey assessed standard practice as the basis for developing “best practices” for ITB for severe spasticity. The online survey was deployed in 2013 to 42 physicians (21 neurologists, 21 PM&R) recruited by an expert panel. Participants had been in practice for >2 years, spent >50% of their time in direct patient care, and currently managed >25 ITB patients being treated for CP, brain injury, stroke, MS, or spinal cord injury.
Results: Patients were pediatric (19%), adult (66%), or geriatric (15%). Physicians always/often used deep tendon reflexes (95%), Manual Muscle Test (84%), and Ashworth/Modified Ashworth Score (83%) to assess spasticity. ITB was generally offered after one or more other therapies had failed. Spasticity interfering with comfort, function and/or caregiving was the main criterion (95%) for considering ITB therapy. Goals included improved quality of life (88%), reduced spasticity (88%), increased comfort (81%), reduced pain (81%), and improved active function (79%).
69% used a screening test (69%) to demonstrate efficacy, and assess patient/caregiver interest in ITB. Before screening, oral antispasmodics were maintained 49% of the time vs. tapering (36%) or weaning (15%). Patient responses were measured at baseline (68%), 1 hr (60%), 2 hrs (68%), 3 hrs (35%) and 4 hrs (60%). Screening results, starting dose, cause of spasticity, and catheter tip placement were reported to the implanter after a successful trial.
There was great variation in timing of postop dose titration and in oral medication weaning. Average minimum doses ranged from 100-170 mcg/day for adults and 50-125 mcg/day for children, with maximum doses varying by diagnosis. Continuous mode dosing was used in 59% of patients; flex dosing was most common for predictable spasticity patterns.
Physicians strongly concurred in sharing emergency information (overdose, underdose, withdrawal, after-hours contact and procedures, manufacturer emergency card) with patients. Loss of ITB efficacy was the most common problem requiring troubleshooting. Equipment problems most often involved catheters or off-schedule dosing/refill issues. The majority of physicians started troubleshooting by collecting a comprehensive patient history (74%) and interrogating the pump (71%). ITB withdrawal was treated most often/always with oral baclofen (71%) or benzodiazepines (43%). 81% of the physicians used an EMR and two-thirds reported their ED had access to it.
Conclusions: Consensus was clear on key metrics, practices, and protocols. Dosing and therapy management were tailored to individual patients and thus more variable.