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Cosyntropin Shows Efficacy for Postdural Puncture Headache
Nancy A. Melville
March 23, 2015
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NATIONAL HARBOR, MD — Intravenous (IV) cosyntropin therapy in the treatment of postdural puncture headache shows efficacy that is similar to that of, but is slower to take effect than, the current gold standard treatment, an epidural blood patch, a new study shows. The findings suggest cosyntropin may offer a lower-cost, noninvasive alternative that could be beneficial in various important settings, researchers say.
"We found that IV cosyntropin proved to be equivalent to epidural blood patch in relieving postdural puncture headache at 3 and 7 days following treatment," said lead author Steven Hanling, MD, from the Naval Medical Center San Diego, California.
"Further studies are needed to elucidate the role of this treatment in the care of postdural puncture headache."
The results were presented here at the American Academy of Pain Medicine (AAPM) 31st Annual Meeting.
Postdural puncture headache, which results from the loss of cerebrospinal fluid and subsequent intracranial hypotension following a dural puncture, is typically also associated with low back pain, nick stiffness, dizziness, tinnitus, and other symptoms.
While an epidural blood patch is considered the front-line treatment for severe, refractory postdural puncture headache, some studies have shown its efficacy is not always reliable, withone study showing it provided persistent relief in only 61% of patients.
Furthermore, adverse effects, although rare, do occur with the epidural blood patch, including severe back pain, bradycardia, and postpartum seizures.
"We're not saying epidural blood patches aren't effective — they are — and we should continue to use them, but we wanted to look into the possibility of some other alternative for this," Dr Hanling said.
Anecdotal reports have suggested adrenocorticotropic hormone derivatives have some benefit in the treatment of postdural puncture headache, with the synthetic derivative cosyntropin in particular showing efficacy compared with placebo for treatment of the headaches, as well as representing a possible prophylactic agent.
To determine how well cosyntropin holds up in a noninferiority study with the epidural blood patch, Dr Hanling and his colleagues randomly assigned 28 patients from 2007 to 2013 to receive the epidural blood patch (n = 13) or IV cosyntropin for postdural puncture headache (n = 15).
Patients had similar characteristics. Results in self-reported pain and function scores were assessed on a 10-point scale before treatment and at days 1, 3, and 7 after treatment.
While improvement in pain and function measures in the epidural blood patch group was significantly greater at day 1 after treatment (P < .001 for both measures), the differences in scores between the two treatment groups were not statistically significant at day 3 or day 7.
There were, however, substantial differences in the percentage of patients returning to the emergency department after treatment for continued headache symptoms: 8.4% of patients in the epidural blood patch vs 60% of patients in the cosyntropin group.
In addition, 16.7% of patients receiving an epidural blood patch required additional treatment compared with 66.7% of cosyntropin patients (both P < .001).
Dr Hanling noted that the differences likely reflect cosyntropin's delayed response compared with the epidural blood patch. "In many of these cases, patients just needed assurance that the treatment would take effect and were sent home," he said.
Mechanisms of cosyntropin believed to relieve postdural puncture headache include a stimulated endorphin release, anti-inflammatory action, fluid and electrolyte retention, and the direct stimulation of cerebral spinal fluid (CSF) production, Dr Hanling explained.
He noted that some of the mechanisms may explain the delay in pain relief compared with the epidural blood patch.
"Mechanisms including fluid and electrolyte retention and direct stimulation of CSF production can take some time, which likely explains why it takes some time to take effect," he said.
Because cosyntropin is linked to hypertension and increased blood glucose, patients who would likely not be good candidates include patients with diabetes, those at risk for infection, and those with blood pressure concerns, Dr Hanling added.
"If you're really worried about systolic blood pressure, then that patient should not be a candidate for this," he said.
Situations when cosyntropin may be particularly beneficial as an alternative to an epidural blood patch include patients who have contraindications to blood patches (eg, those with coagulopathy), certain malignancies, and efforts to spare pediatric pain patients additional epidural injections.
The IV cosyntropin may also be a useful alternative in settings where epidural blood patches cannot be easily provided, Dr Hanling added.
"If you look around the country, many emergency department or urgent care clinics may be staffed by providers who can do a lumbar puncture but who don't have the training or credentialing to do an epidural blood patch, and those settings may benefit from the IV cosyntropin."
Possible Alternative
James C. Watson, MD, a pain specialist and neurologist with the Mayo Clinic, Rochester, Minnesota, who moderated the session, noted that while epidural blood patches are generally reliable in the treatment for postdural puncture headache, insights into a possible alternative to the treatment are valuable.
"Epidural blood patch is a generally safe procedure and complications are very rare, but it is not without risk and those risks can have significant associated morbidity," he told Medscape Medical News.
"A noninvasive IV treatment would allow treatment to be administered immediately on symptom recognition regardless of where that patient interaction occurs; be used in situations where epidural blood patch is contraindicated; and eliminate any even limited risk from an intervention," he said.
"It allows treatment without having to arrange for specialists with the capability of performing an epidural blood patch."
The study received no outside funding. Dr Hanling and Watson have disclosed no relevant financial relationships.
American Academy of Pain Medicine (AAPM) 31st
Nancy A. Melville
March 23, 2015
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Receive an email from Medscape whenever new articles on this topic are available.
DRUG & REFERENCE INFORMATION
Add Headache to My Topic AlertNATIONAL HARBOR, MD — Intravenous (IV) cosyntropin therapy in the treatment of postdural puncture headache shows efficacy that is similar to that of, but is slower to take effect than, the current gold standard treatment, an epidural blood patch, a new study shows. The findings suggest cosyntropin may offer a lower-cost, noninvasive alternative that could be beneficial in various important settings, researchers say.
"We found that IV cosyntropin proved to be equivalent to epidural blood patch in relieving postdural puncture headache at 3 and 7 days following treatment," said lead author Steven Hanling, MD, from the Naval Medical Center San Diego, California.
"Further studies are needed to elucidate the role of this treatment in the care of postdural puncture headache."
The results were presented here at the American Academy of Pain Medicine (AAPM) 31st Annual Meeting.
Postdural puncture headache, which results from the loss of cerebrospinal fluid and subsequent intracranial hypotension following a dural puncture, is typically also associated with low back pain, nick stiffness, dizziness, tinnitus, and other symptoms.
While an epidural blood patch is considered the front-line treatment for severe, refractory postdural puncture headache, some studies have shown its efficacy is not always reliable, withone study showing it provided persistent relief in only 61% of patients.
Furthermore, adverse effects, although rare, do occur with the epidural blood patch, including severe back pain, bradycardia, and postpartum seizures.
"We're not saying epidural blood patches aren't effective — they are — and we should continue to use them, but we wanted to look into the possibility of some other alternative for this," Dr Hanling said.
Anecdotal reports have suggested adrenocorticotropic hormone derivatives have some benefit in the treatment of postdural puncture headache, with the synthetic derivative cosyntropin in particular showing efficacy compared with placebo for treatment of the headaches, as well as representing a possible prophylactic agent.
To determine how well cosyntropin holds up in a noninferiority study with the epidural blood patch, Dr Hanling and his colleagues randomly assigned 28 patients from 2007 to 2013 to receive the epidural blood patch (n = 13) or IV cosyntropin for postdural puncture headache (n = 15).
Patients had similar characteristics. Results in self-reported pain and function scores were assessed on a 10-point scale before treatment and at days 1, 3, and 7 after treatment.
While improvement in pain and function measures in the epidural blood patch group was significantly greater at day 1 after treatment (P < .001 for both measures), the differences in scores between the two treatment groups were not statistically significant at day 3 or day 7.
There were, however, substantial differences in the percentage of patients returning to the emergency department after treatment for continued headache symptoms: 8.4% of patients in the epidural blood patch vs 60% of patients in the cosyntropin group.
In addition, 16.7% of patients receiving an epidural blood patch required additional treatment compared with 66.7% of cosyntropin patients (both P < .001).
Dr Hanling noted that the differences likely reflect cosyntropin's delayed response compared with the epidural blood patch. "In many of these cases, patients just needed assurance that the treatment would take effect and were sent home," he said.
Mechanisms of cosyntropin believed to relieve postdural puncture headache include a stimulated endorphin release, anti-inflammatory action, fluid and electrolyte retention, and the direct stimulation of cerebral spinal fluid (CSF) production, Dr Hanling explained.
He noted that some of the mechanisms may explain the delay in pain relief compared with the epidural blood patch.
"Mechanisms including fluid and electrolyte retention and direct stimulation of CSF production can take some time, which likely explains why it takes some time to take effect," he said.
Because cosyntropin is linked to hypertension and increased blood glucose, patients who would likely not be good candidates include patients with diabetes, those at risk for infection, and those with blood pressure concerns, Dr Hanling added.
"If you're really worried about systolic blood pressure, then that patient should not be a candidate for this," he said.
Situations when cosyntropin may be particularly beneficial as an alternative to an epidural blood patch include patients who have contraindications to blood patches (eg, those with coagulopathy), certain malignancies, and efforts to spare pediatric pain patients additional epidural injections.
The IV cosyntropin may also be a useful alternative in settings where epidural blood patches cannot be easily provided, Dr Hanling added.
"If you look around the country, many emergency department or urgent care clinics may be staffed by providers who can do a lumbar puncture but who don't have the training or credentialing to do an epidural blood patch, and those settings may benefit from the IV cosyntropin."
Possible Alternative
James C. Watson, MD, a pain specialist and neurologist with the Mayo Clinic, Rochester, Minnesota, who moderated the session, noted that while epidural blood patches are generally reliable in the treatment for postdural puncture headache, insights into a possible alternative to the treatment are valuable.
"Epidural blood patch is a generally safe procedure and complications are very rare, but it is not without risk and those risks can have significant associated morbidity," he told Medscape Medical News.
"A noninvasive IV treatment would allow treatment to be administered immediately on symptom recognition regardless of where that patient interaction occurs; be used in situations where epidural blood patch is contraindicated; and eliminate any even limited risk from an intervention," he said.
"It allows treatment without having to arrange for specialists with the capability of performing an epidural blood patch."
The study received no outside funding. Dr Hanling and Watson have disclosed no relevant financial relationships.
American Academy of Pain Medicine (AAPM) 31st
