Use of antiplatelet agents is becoming increasingly common, and their management may require
new strategies if neuroaxial techniques are to be employed in patients who will not tolerate
discontinuation of antiplatelet therapy.
The patient was a 46-year-old man with a past medical history significant for coronary artery
disease and who had undergone 14 stents. He developed stent thrombosis (ST) while on
clopidogrel. Following the ST, he was subsequently placed on prasugrel. While on prasugrel, the
patient presented for an intrathecal drug delivery system (IDDS) trial and placement due to severe
peripheral neuropathy unresponsive to several conservative medical treatments. He had previously
undergone an unsuccessful spinal cord stimulator trial and received no pain relief. In consultation
with his outside cardiologist, the patient received permission to hold his prasugrel for 7 days
prior to his intrathecal pump trial. During the trial period’s inpatient hospitalization, the patient
developed chest pain. In consultation with the cardiology service in our institution, it was decided
antiplatelet therapy should be re-instituted. The patient was bridged to his IDDS placement after
the trial with intravenous eptifibatide. The eptifibatide drip was administered 6 hours prior to the
IDDS implant. Functional platelet count was checked one hour before the IDDS was placed and
the pump was placed without incident. The eptifibatide drip was reinstituted one hour after the
IDDS implantation. The patient was observed for 24 hours on the eptifibatide drip, transitioned to
his home dose of prasugrel, and discharged home. At outpatient follow-up one week later, the
patient demonstrated no neurologic or hemorrhagic complications and was satisfied with the pain
control provided by the IDDS.
Prasugrel is an irreversible platelet inhibitor, which prevents ADP-induced platelet aggregation
by binding the P2Y12 receptor. Patients taking prasugrel will have deficient platelet activity until
new platelets have been produced, a span of approximately 7 days. Eptifibatide is an intravenous
glycoprotein IIb/IIIa inhibitor with a short half-life of 2½ hours. Inhibition of glycoprotein IIb/IIIa
prevents platelet activation and aggregation. The drug effect ceases once it is discontinued and
restoration of platelet function is not dependent upon new platelet production.
Patients requiring antiplatelet therapy in need of neuroaxial pain management procedures present
challenging problems to pain management physicians. Current guidelines from the American
Society of Regional Anesthesia have not identified any bridging agent suitable for patients who
may not tolerate prolonged withdrawal from their antiplatelet therapy. In this case, eptifibatide
was successfully utilized to bridge a patient whose comorbid conditions necessitated continuous
antiplatelet therapy without the prolonged washout common to irreversible antiplatelet agents.
Key words: Intrathecal drug delivery system, anticoagulation, pain, eptifibatide, antiplatelet
agents.
Intrathecal Drug Delivery System for Chronic Pain Management
