Zusammenfassung
□ Hintergrund
Myoklonien sind eine mögliche Nebenwirkung einer Opioidtherapie, und sind swohl nach systemischer wie nach rückenmarksnaher Applikation beschrieben worden.
□ Falldarstellung
Berichtet wird der Fall einer Patientin mit metastasiertem Rektumkarzinom, die als Folge einer hochdosierten epiduralen und kombiniert intravenösen Morphininfusion ausgeprägte Myoklonien entwickelte. Diese Komplikation trat bei maximalen Tagesdosierungen von epidural 300 mg und intravenös 80 mg auf und verschwand vollständig nach Dosisreduktion. Behandlungsversuche werden dargestellt, die Pathophysiologie der Myoklonien wird diskutiert.
□ Schlußfolgerung
Zur Behandlung opioidinduzierter Myoklonien sollte neben der symptomatischen Therapie mit Benzodiazepinen oder Baclofen ein Wechsel oder eine Dosisreduktion des Opioids erwogen werden.
Summary
□ Background
Myocloni are a possible side effect of opioid therapy, and have been described following systemic as well as spinal application.
□ Case Report
We report the case of a patient with metastatic carcinoma of the rectum who developed myoclonus following administration of high-dose epidural combined with iv morphine. This complication occured with maximum daily doses of 300 mg epidurally and 80 mg intravenously and disappeared completely after dose reduction. Treatment trials are presented, the pathophysiology of the myoclonus is discussed.
□ Conclusion
For treatment of opioid-induced myoclonus a dose reduction or a change of the opioid should be considered as well as symptomatic treatment with benzodiazepines or baclofen.
Literatur
Adair, J. C.: Fentanyl neurotoxicity. Ann. Emerg. Med. 27 (1996), 791–792.
Ali, N. M. K.: Hyperalgesic response in a patient receiving high concentrations of spinal morphine. Anesthesiology 65 (1986), 449.
Arner, S., N. Rawal, L. L. Gustafsson: Clinical experience of long-term treatment with epidural opioids — a nationwide survey. Acta anaesth. scand. 32 (1988), 253–259.
Ashby, M. A., B. Rounsefell, F. Bochner, A. Somogyi, J. Van Crugten: Myoclonus and central nervous system complication of high-dose opioid administration. 1st Cong. of the Eur. Assoc. for Palliative Care, Abstract Book, Paris 1990, p. 134.
Beyer, C., L. A. Roberts, B. R. Komisaruk: Hyperalgesia induced by altered glycerinic activity at the spinal cord. Life Sci. 37 (1985), 875–882.
Cherny, N. J., V. Chang, G. Frager, J. M. Ingham, P. J. Tiseo, B. Papp, R. K. Portenoy, K. M. Foley: Opioid pharmacotherapy in the management of cancer pain: a survey of strategies used by pain physicians for the selection of analgesic drugs and routes of administration. Cancer 76 (1995), 1283–1293.
De Armendi, A. J., M. Fahey, J. F. Ryan: Morphine-induced myoclonic movements in a pediatric pain patient. Anesth. Analg. 77 (1993), 191–192.
De Conno, F., A. Caraceni, C. Martini, E. Spoldi, M. Salvetti, V. Ventafridda. Hyperalgesia and myoclonus with intrathecal infusion of high-dose morphine. Pain 47 (1991), 337–339.
Dralle, D., H. Müller, J. Zierski, N. Klug: Intrathecal baclofen for spasticity. Lancet II (1985), 1003.
Eisele, J. H., E. J. Grigsby, G. Dea: Clonazepam treatment of myoclonic contractions associated with high-dose opioids; case report. Pain 49 (1992), 231–232.
Ferris, F. D., I. G. Kerr, C. De Angelis, M. Sone, S. Hume: Inpatient narcotic infusions for patients with cancer pain. J. Palliat. Care 6 (1990), 51–59.
Glare, P., D. Sheehan, E. Smyth, D. Walsh: A pilot study of the side effects of morphine sulfate in advanced cancer. 1st Cong. of the Eur. Assoc. for Palliative Care. Abstract Book, Paris 1990, p. 139.
Glare, P. A., T. D. Walsh, C. E. Pippenger: Nonnorphine, a neurotoxic metabolite? Lancet 335 (1990), 725–726.
Glavina, M. J., R. Robertshaw: Myoclonic spasms following intrathecal morphine. Anaesthesia 43 (1988), 389–390.
Groudine, S. B., C. Cresanti-Daknis, P. D. Lumb: Successful treatment of a massive intrathekal overdose. Anesthesiology 82 (1995), 292–295.
Holland, K. D., A. C. McKeon, D. J. Canney, D. F. Covey, J. A. Ferrendelli: Relative anticonvulsant effects of GABA mimetic and GABA modulatory agents. Epilepsia 33 (1992), 981–986.
Jaffe, J. H., W. R. Martin: Opioid analgesics and antagonists. In: Goodman-Gilman, A., L. S. Goodman, T. W. Rall, F. Murad (eds.): Goodman and Gilman’s the Pharmacological Basis of Therapeutics. 7th ed., MacMillan, New York 1985, p. 491–531.
Klitenick, M. A., P. DeWitte, P. Kalivas: Regulation of somatodendritic dopamine release in the ventral tegmental area by opioids and GABA: an in vivo microdialysis study. J. Neurosci. 12 (1992), 2623–2632.
Kloke, M., U. Bingel, S. Seeber: Complications of spinal opioid therapy: myoclonus, spastic muscle tone and spinal jerking. Support Care Cancer 2 (1994), 249–252.
Krames, E. S., J. Gershow, A. Glassberg, T. Kenefick, A. Lyons, P. Taylor, D. Wilkie: Continuous infusion of spinally administered narcotics for pain due to malignant disorders. Cancer (Philad.) 56 (1985), 696–702.
Littrell, R. A., D. Kennedy, W. E. Birmingham, W. D. Leak: Muscle spasms associated with intrathecal morphine therapy: treatment with midazolam. Clin. Pharm. 11 (1992), 57–59.
Meisel, S. B., P. K. Welford: Seizures associated with high-dose intravenous morphine containing sodium bisulfite preservative. Ann. Pharmacol. 26 (1992), 1515–1517.
Mercadanate, S.: Dantrolene treatment of opioid-induced myoclonus. Anesth. Analg. 81 (1995), 1307–1308.
Müller, H., H. Gerlach, J. Boldt, U. Börner, P. Hild, K. U. Oehler, J. Zierski, G. Hempelmann: Spastik-Behandlung mit rückenmarksnaher Gabe von Morphin oder Midazolam. Anästhesist 35 (1986), 306–316.
Müller, H., J. Zierski, R. D. Penn: Local-spinal therapy of spasticity. Springer, Berlin-Heidelberg-New York 1988.
Obesa, J. A., J. Artieda, C. D. Marsden: Different clinical presentations of myoclonus. In: Jankovic, J., E. Tolosa (Hrsg.): Parkinson’s disease and movement disorders, 2. Auflage. Williams and Wilkins, Baltimore 1993, p. 315–328.
Ochs, G. A.: Intrathecal baclofen. Baillieres Clin. Neurol. 2 (1993), 73–86.
Parkinson, S. K., S. L. Bailey, W. L. Little, J. B. Mueller: Myoclonic seizure activity with chronic high-dose spinal opioid administration. Anesthesiology 72 (1990), 743–745.
Penn, R. D., J. S. Kroin: Long-term intrathecal baclofen infusion for treatment of spasticity. J. Neurosurg. 66 (1987), 181–185.
Penn, R., J. Paice: Chronic intrathecal morphine for intractable pain. J. Neurosurg. 67 (1987), 182–186.
Potter, J. M., D. B. Reid, R. J. Shaw, P. Hackett, P. E. Hickman. Myoclonus associated with treatment with high doses of morphine: the role of supplemental drugs. Brit. med. J. 299 (1989), 150–153.
Shohami, E., S. Evron: Intrathecal morphine induces myoclonic seizures in the rat. Acta pharmacol. Toxicol. 56 (1985), 50–54.
Sjögren, P., N. H. Jensen, T. S. Jensen: Disappearance of morphine-induced hyperalgesia after discontinuing or substituting morphine with other opioid agonists. Pain 59 (1994), 313–316.
Sjögren, P., L. Dragsted, C. B. Christensen: Myoclonic spasms during treatment with high doses of intravenous morphine in renal failure. Acta anaesth. scand. 37 (1993), 780–782.
Sjögren, P., T. Jonsson, N. H. Jensen, N. E. Drenck, T. S. Jensen: Hyperalgesia and myoclonus in terminal cancer patients treated with continuous intravenous morphine. Pain 55 (1993), 93–97.
Stillman, M. J., D. E. Moulin, K. E. Foley: Paradoxical pain following high-dose spinal morphine. Pain, Suppl. 4 (1987), S389.
Tursky, L., W. Niemann, D. N. Stephens: Differential effects of antiepileptic drugs and beta-carbolines on seizures induced by excitatory amino acids. Neuroscience 39 (1990), 799–807.
Twycross, R.: Pain relief in advanced cancer. Churchill Livingston, Edinburgh 1994, p. 372.
Ventafridda, V., L. Saita, L. Barletta, A. Sbanotto, F. De Conno: Clinical observation on controlled-release morphine in cancer pain. J. Pain Symptom. Manage. 4 (1989), 124–129.
Wetz, M. A., R. L. MacDonald: Opiate alkaloids antagonize postsynaptic glycine and GABA responses: correlation with convulsant action. Brain Res. 236 (1982), 107–119.
Yaksh, T. L.: Behavioral and autonomic correlates of the tactile evoked allodynia produced by spinal glycine inhibition: effects of modulatory receptor systems and excitatory amino acids antagonists. Pain 37 (1989), 111–123.
Yaksh, T. L., G. J. Harty, B. M. Onofrio: High doses of spinal morphine produce a nonopiate receptor mediated hyperesthesia: clinical and theoretic implications. Anesthesiology 64 (1986), 590–597.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Radbruch, L., Zech, D. & Grond, S. Myoklonien als Folge von hochdosierter epiduraler und intravenöser Morphininfusion. Med. Klin. 92, 296–299 (1997). https://doi.org/10.1007/BF03045086
Issue Date:
DOI: https://doi.org/10.1007/BF03045086