Ziconotide
Pronunciation: zye-KOE-noe-tide.
- Generic name
- ziconotide
- Brand names
- Prialt
- Drug class
- N-type calcium channel blocker; non-opioid analgesic (synthetic cone-snail venom peptide)
- Form
- Solution for intrathecal infusion (25 mcg/mL and 100 mcg/mL strengths)
- Route
- Intrathecal infusion ONLY — never intravenous, never oral
- Legal status
- Prescription-only medicine, administered only by physicians experienced in intrathecal therapy
Supply Rules Vary
Trade names by country: United States · United Kingdom
Australia: · Full directory
What ziconotide is and how it works
Ziconotide (brand name Prialt) is a non-opioid pain-relieving medicine, a synthetic version of a peptide found in the venom of a cone snail (Conus magus). It works by blocking calcium channels on nerve cells in the spinal cord that carry pain signals. It carries a boxed warning — the strongest warning the US FDA applies to a medicine label — because severe psychiatric symptoms and neurological impairment may occur during treatment. It is given ONLY by intrathecal infusion (directly into the fluid-filled space around the spinal cord), through a pump and catheter system managed by a specialist team; it is explicitly not intended for intravenous administration, and there is no oral form. (1) (2) (3)
Ziconotide is used for severe, long-term pain in adults who need pain relief delivered directly into the spinal fluid space (intrathecal analgesia), usually because other treatments — including oral or intravenous painkillers and even intrathecal morphine — have not worked well enough or have not been tolerated. Because of its boxed warning, you will be closely monitored for changes in mood, thinking, or consciousness throughout treatment.
What ziconotide is used for
Severe chronic pain requiring intrathecal therapy
Ziconotide is indicated for the management of severe, chronic pain in adults for whom intrathecal (spinal) therapy is warranted, and who are intolerant of or have not responded well to other treatments such as systemic (oral or intravenous) analgesics, other adjunctive pain therapies, or intrathecal morphine. (1) (2) (3)
Before taking ziconotide
Do not take / not appropriate for
- Do not receive ziconotide if you have a pre-existing history of psychosis. This is a specific contraindication because of the medicine's real risk of causing or worsening psychiatric symptoms. (all products) (1)
- Do not receive ziconotide if you have known hypersensitivity to ziconotide or any component of the formulation, or if you have any condition that would make intrathecal (spinal) administration hazardous, such as infection at the injection/pump site, uncontrolled bleeding, or a spinal canal obstruction. (all products) (1)
Tell your clinician about
- Any personal or family history of psychosis, hallucinations, or other serious mental health condition.
- Any history of depression or suicidal thoughts.
- Any infection, bleeding disorder, or spinal condition that could make intrathecal administration risky.
- All other medicines you take, especially any opioid pain medicines (systemic or intrathecal) — these must be tapered gradually if treatment changes, never stopped abruptly.
- Pregnancy, plans for pregnancy, or breastfeeding.
How to take ziconotide
- Ziconotide is given ONLY by intrathecal infusion — directly into the fluid-filled space around the spinal cord — through an implanted or external pump and catheter system, managed exclusively by physicians and teams experienced in intrathecal drug delivery.
- It is never given intravenously, into a muscle, or by mouth. The US prescribing information explicitly states it is 'not intended for intravenous administration.'
- Dosing is started low and increased gradually and individually by your specialist team based on your pain relief and any side effects — there is no standard starting dose you would ever self-administer or adjust.
- If you are also taking opioid pain medicines, any change to those medicines must be done gradually (tapering), never suddenly, to avoid withdrawal — this is managed entirely by your treating team.
Procedures and treatment changes
Tell the treating team before surgery, procedures, or any medicine change. Do not alter treatment without the responsible clinician. (1) (2) (3)
Missed dose
Because ziconotide is delivered continuously by a specialist-managed pump system, not as individual patient-administered doses, any concern about the infusion (such as a pump alarm, suspected malfunction, or missed clinic visit for a refill) should be reported to your treating team immediately rather than adjusted by you.
Overdose
An overdose or infusion malfunction is managed immediately by the treating clinical team, since the pump and catheter system is under their direct control. Seek urgent medical attention for any sudden worsening of confusion, reduced consciousness, or new neurological symptoms. (1)
Side effects
In clinical trials, the large majority of patients (88% in the UK product information) experienced at least one side effect. Some are common; others, described below, are serious and require urgent attention.
Dizziness
What to notice: Feeling unsteady or light-headed. This was one of the most common side effects reported (occurring in 25% or more of patients).
What to do: Avoid driving or operating machinery if affected. Tell your care team if severe. (1)
Nausea
What to notice: Feeling sick, one of the most commonly reported effects.
What to do: Tell your care team if persistent or severe. (1)
Confusional state and nystagmus (abnormal eye movements)
What to notice: New confusion or noticeable involuntary eye movements were also very commonly reported.
What to do: Report any new confusion promptly to your care team, since this overlaps with the boxed-warning risk described below. (1)
Serious warnings
Severe psychiatric symptoms and neurological impairment (boxed warning) — emergency
Symptoms: Hallucinations, paranoia, psychosis, marked confusion, new or worsening depression or suicidal thoughts, or reduced consciousness.
Action: This is the medicine's boxed warning — the most serious safety warning a regulator can apply. Seek emergency medical attention and contact your treating team immediately for any of these symptoms. (1) (2)
Meningitis (particularly with external infusion devices) — emergency
Symptoms: Fever, severe headache, neck stiffness, sensitivity to light.
Action: Seek emergency medical attention immediately. (1)
Marked elevation of creatine kinase (muscle enzyme) — urgent
Symptoms: Muscle pain, cramps, or weakness; often only detected on a monitoring blood test.
Action: Attend all scheduled blood tests during treatment; report new muscle symptoms to your care team promptly. (1)
Interactions
| Medicine or test | Effect | Action |
|---|---|---|
| Opioid pain medicines (systemic or intrathecal, e.g. intrathecal morphine) | If opioids are being used alongside or are replaced by ziconotide, they must be tapered gradually rather than stopped suddenly, to avoid withdrawal symptoms. | Your specialist team will plan and manage any change to your opioid medicines; never stop an opioid abruptly yourself. (1) |
| Other centrally-acting or sedating medicines | No specific drug-drug interaction table beyond general precautions was identified in the reviewed sources; ziconotide's own sedative/cognitive side effects (dizziness, confusion, drowsiness) may add to those of other central nervous system-acting medicines. | Tell your specialist team about all other medicines you take. |
Pregnancy, breastfeeding, kidney/liver function, age
Patients with a history of psychosis
Ziconotide is contraindicated in anyone with a pre-existing history of psychosis, given its real risk of causing or worsening psychiatric symptoms. (1)
Patients with depression or suicidal ideation
Close monitoring for new or worsening depression or suicidal thoughts is required throughout treatment as part of the boxed-warning safety plan. (1) (2)
Pregnancy and breastfeeding
Specific pregnancy and breastfeeding safety data were not detailed in the reviewed sources beyond general caution; this gap is disclosed honestly. Discuss any pregnancy plans or breastfeeding with your specialist team before starting or continuing treatment.
Patients using an external infusion device
External (rather than fully implanted) infusion devices carry a materially higher reported meningitis risk in the reviewed US label. Your team will discuss the device type used for your treatment and the associated precautions. (1)
Monitoring
Before starting
- A neuropsychiatric evaluation, to establish a baseline and screen for a pre-existing history of psychosis (a contraindication).
- Assessment of suitability for an intrathecal pump/catheter system, including screening for infection, bleeding risk, or spinal canal obstruction at the intended site.
- Baseline creatine kinase (CK) level.
During treatment
- Frequent neuropsychiatric assessment for cognitive impairment, hallucinations, or changes in mood or consciousness — immediately if any depressive signs or symptoms appear.
- Periodic serum CK monitoring (for example, every other week for the first month, then monthly, per the reviewed US label).
- Clinical evaluation for muscle-related symptoms (myalgia, cramps).
- Ongoing review for signs of meningitis, especially with an external infusion device.
- Advice not to drive or operate machinery if dizziness, confusion, or drowsiness occurs.
Storage
Ziconotide is stored, prepared, and loaded into the infusion pump system by pharmacy and clinical staff according to the specific product's instructions; it is not stored or handled by patients at home.
Professional information
Clinician-facing summary. Always consult current local prescribing information, particularly given the specialist, device-based delivery method.
United States
Indication: Severe chronic pain in adults requiring intrathecal therapy, intolerant of or refractory to other treatment
Dose summary: Initiate at no more than 2.4 mcg/day (0.1 mcg/hr); titrate upward by up to 2.4 mcg/day (0.1 mcg/hr) at intervals of no more than 2-3 times per week; recommended maximum 19.2 mcg/day (0.8 mcg/hr) by day 21.
Renal context: Not specifically detailed in the reviewed US label beyond general monitoring requirements. (1)
United Kingdom / European Union
Indication: Severe, chronic pain in adults requiring intrathecal analgesia
Dose summary: Initiated at no more than 2.4 micrograms/day, titrated individually according to analgesic response and adverse reactions; treatment only undertaken by physicians experienced in intrathecal administration.
Renal context: Not specifically detailed in the reviewed UK/EU sources beyond general monitoring requirements. (2) (3)
Canada, Australia, New Zealand
Indication: Unverified
Dose summary: No current, live-verifiable marketing authorisation, product information, or dosing guidance was located for any of these countries within this session's research. Regulatory status is not asserted either way.
Renal context: Not applicable — unverified.
Frequently asked questions
Does ziconotide have a boxed warning?
Yes. Ziconotide (Prialt) carries a real, verified FDA boxed warning — the strongest warning a US drug label can carry — stating that severe psychiatric symptoms and neurological impairment may occur during treatment. It is contraindicated in anyone with a pre-existing history of psychosis. (1)
Can ziconotide be given as a normal injection or IV drip?
No. Ziconotide is given only by intrathecal infusion — directly into the fluid-filled space around the spinal cord — through a specialist-managed pump and catheter system. The US prescribing information explicitly states it is 'not intended for intravenous administration,' and there is no oral form. (1) (2)
What monitoring will I have while on ziconotide?
Frequent neuropsychiatric assessments (checking for cognitive changes, hallucinations, or mood changes), periodic blood tests for creatine kinase (a muscle enzyme), and ongoing review for signs of meningitis, especially if you use an external infusion device. (1) (2)
Is ziconotide available in Canada, Australia, or New Zealand?
This could not be confirmed from a live official regulator source (Health Canada, Australian TGA/ARTG, or New Zealand Medsafe) at the time of writing. Availability in these countries is not asserted either way.
Can I stop my opioid pain medicine suddenly if I start ziconotide?
No. If you are taking opioid pain medicines (by any route, including intrathecal morphine), any change must be tapered gradually by your treating team, never stopped abruptly, to avoid withdrawal. (1)
References
- PRIALT (ziconotide) injection, solution -- prescribing informationU.S. National Library of Medicine, DailyMed · United States · accessed 2026-07-31 · source 1
- Prialt 100 micrograms/mL (and 25 micrograms/mL) solution for infusion -- Summary of Product Characteristicselectronic Medicines Compendium (UK) · United Kingdom · accessed 2026-07-31 · source 2
- Prialt, INN-ziconotide -- European Public Assessment Report (EPAR) product informationEuropean Medicines Agency · European Union · dated 2005-02-21 · accessed 2026-07-31 · source 3
Brand names by country
Single-ingredient ziconotide names are shown separately by country. Product availability, strengths, and supply rules can change; combination products are not included here.
Priority countries
United States
- PRIALT100 ug/mL, 500 ug/5mL, 25 ug/mL, 500 ug/20mL · esteve pharmaceuticals, s.a.
United Kingdom
- Prialt (2)current licensed product · 25 micrograms/mL, 100 micrograms/mL · See current UK EMC SmPC
View brands in additional countries.
European Union
Prialt (3)