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Zhang S, Pu Y, Liu J, Li L, An C, Wu Y, Zhang W, Zhang W, Qu S, Yan W. Exploring the multifaceted potential of (R)-ketamine beyond antidepressant applications. Front Pharmacol 2024; 15:1337749. [PMID: 38666026 PMCID: PMC11043571 DOI: 10.3389/fphar.2024.1337749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 04/01/2024] [Indexed: 04/28/2024] Open
Abstract
(R, S)- and (S)-ketamine have made significant progress in the treatment of treatment-resistant depression (TRD) and have become a research focus in recent years. However, they both have risks of psychomimetic effects, dissociative effects, and abuse liability, which limit their clinical use. Recent preclinical and clinical studies have shown that (R)-ketamine has a more efficient and lasting antidepressant effect with fewer side effects compared to (R, S)- and (S)-ketamine. However, a recent small-sample randomized controlled trial found that although (R)-ketamine has a lower incidence of adverse reactions in adult TRD treatment, its antidepressant efficacy is not superior to the placebo group, indicating its antidepressant advantage still needs further verification and clarification. Moreover, an increasing body of research suggests that (R)-ketamine might also have significant applications in the prevention and treatment of medical fields or diseases such as cognitive disorders, perioperative anesthesia, ischemic stroke, Parkinson's disease, multiple sclerosis, osteoporosis, substance use disorders, inflammatory diseases, COVID-19, and organophosphate poisoning. This article briefly reviews the mechanism of action and research on antidepressants related to (R)-ketamine, fully revealing its application potential and development prospects, and providing some references and assistance for subsequent expanded research.
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Affiliation(s)
- Senbing Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
- Department of Anesthesiology, Xianning Central Hospital, The First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, China
| | - Yanzhu Pu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Jianning Liu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Lewen Li
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Chibing An
- Department of Anesthesiology, Xianning Central Hospital, The First Affiliated Hospital of Hubei University of Science and Technology, Xianning, Hubei, China
| | - Yumin Wu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenjie Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenxia Zhang
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Song Qu
- The First Clinical Medical College, Gansu University of Chinese Medicine, Lanzhou, China
| | - Wenjun Yan
- Department of Anesthesiology, Gansu Provincial Hospital, Lanzhou, Gansu, China
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S-ketamine: Is it a ride worth taking? Adverse effects associated with S-ketamine use as an adjuvant or single agent drug. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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Mahmoudzade S, Goudarzi S, Mohammad Jafari R, Shafaroodi H, Dehpour AR, Sanatkar M. The N‐methyl‐D‐aspartate receptor antagonist ketamin exerts analgesic effects via modulation of the nitric oxide pathway. Fundam Clin Pharmacol 2022; 36:956-965. [DOI: 10.1111/fcp.12816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/26/2022] [Accepted: 07/07/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Shamim Mahmoudzade
- Toxicology and Pharmacology Department, Pharmaceutical Sciences Branch Islamic Azad University Tehran Iran
| | - Sepideh Goudarzi
- Experimental Medicine Research Center Tehran University of Medical Sciences Tehran Iran
- Faculty of Pharmacy Tehran University of Medical Sciences Tehran Iran
| | | | - Hamed Shafaroodi
- Toxicology and Pharmacology Department, Pharmaceutical Sciences Branch Islamic Azad University Tehran Iran
- Experimental Medicine Research Center Tehran University of Medical Sciences Tehran Iran
- Department of Pharmacology, School of Medicine Tehran University of Medical Sciences Tehran Iran
| | - Ahmad Reza Dehpour
- Experimental Medicine Research Center Tehran University of Medical Sciences Tehran Iran
- Department of Pharmacology, School of Medicine Tehran University of Medical Sciences Tehran Iran
| | - Mehdi Sanatkar
- Anesthesiology and Pain Management Department Farabi Hospital, Tehran University of Medical Science Tehran Iran
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Abstract
BACKGROUND Ketamine produces potent analgesia combined with psychedelic effects. It has been suggested that these two effects are associated and possibly that analgesia is generated by ketamine-induced dissociation. The authors performed a post hoc analysis of previously published data to quantify the pharmacodynamic properties of ketamine-induced antinociception and psychedelic symptoms. The hypothesis was that ketamine pharmacodynamics (i.e., concentration-effect relationship as well as effect onset and offset times) are not different for these two endpoints. METHODS Seventeen healthy male volunteers received escalating doses of S- and racemic ketamine on separate occasions. Before, during, and after ketamine infusion, changes in external perception were measured together with pain pressure threshold. A population pharmacokinetic-pharmacodynamic analysis was performed that took S- and R-ketamine and S- and R-norketamine plasma concentrations into account. RESULTS The pharmacodynamics of S-ketamine did not differ for antinociception and external perception with potency parameter (median [95% CI]) C50, 0.51 (0.38 to 0.66) nmol/ml; blood-effect site equilibration half-life, 8.3 [5.1 to 13.0] min), irrespective of administration form (racemic ketamine or S-ketamine). R-ketamine did not contribute to either endpoint. For both endpoints, S-norketamine had a small antagonistic effect. CONCLUSIONS The authors conclude that their data support an association or connectivity between ketamine analgesia and dissociation. Given the intricacies of the study related to the pain model, measurement of dissociation, and complex modeling of the combination of ketamine and norketamine, it is the opinion of the authors that further studies are needed to detect functional connectivity between brain areas that produce the different ketamine effects. EDITOR’S PERSPECTIVE
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Binding of esketamine to human serum albumin for clinical implications. J INCL PHENOM MACRO 2021. [DOI: 10.1007/s10847-021-01090-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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How relevant is stereoselectivity to the side-effects of ketamine? Br J Anaesth 2021; 127:1-2. [PMID: 33965204 DOI: 10.1016/j.bja.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022] Open
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Kamp J, van Velzen M, Aarts L, Niesters M, Dahan A, Olofsen E. Stereoselective ketamine effect on cardiac output: a population pharmacokinetic/pharmacodynamic modelling study in healthy volunteers. Br J Anaesth 2021; 127:23-31. [PMID: 33896589 PMCID: PMC8258972 DOI: 10.1016/j.bja.2021.02.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 02/03/2021] [Accepted: 02/25/2021] [Indexed: 11/19/2022] Open
Abstract
Background Ketamine has cardiac excitatory side-effects. Currently, data on the effects of ketamine and metabolite concentrations on cardiac output are scarce. We therefore developed a pharmacodynamic model derived from data from a randomised clinical trial. The current study is part of a larger clinical study evaluating the potential mitigating effect of sodium nitroprusside on the psychedelic effects of ketamine. Methods Twenty healthy male subjects received escalating esketamine and racemic ketamine doses in combination with either placebo or sodium nitroprusside on four visits: (i) esketamine and placebo, (ii) esketamine and sodium nitroprusside, (iii) racemic ketamine and placebo, and (iv) racemic ketamine and sodium nitroprusside. During each visit, arterial blood samples were obtained and cardiac output was measured. Nonlinear mixed-effect modelling was used to analyse the cardiac output time-series data. Ketamine metabolites were added to the model in a sequential manner to evaluate the effects of metabolites. Results A model including an S-ketamine and S-norketamine effect best described the data. Ketamine increased cardiac output, whereas modelling revealed that S-norketamine decreased cardiac output. No significant effects were detected for R-ketamine, metabolites other than S-norketamine, or sodium nitroprusside on cardiac output. Conclusions S-Ketamine, but not R-ketamine, increased cardiac output in a dose-dependent manner. In contrast to S-ketamine, its metabolite S-norketamine reduced cardiac excitation in a dose-dependent manner. Clinical trial registration Dutch Cochrane Center 5359.
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Affiliation(s)
- Jasper Kamp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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Abstract
BACKGROUND Several models describing the pharmacokinetics of ketamine are published with differences in model structure and complexity. A systematic review of the literature was performed, as well as a meta-analysis of pharmacokinetic data and construction of a pharmacokinetic model from raw data sets to qualitatively and quantitatively evaluate existing ketamine pharmacokinetic models and construct a general ketamine pharmacokinetic model. METHODS Extracted pharmacokinetic parameters from the literature (volume of distribution and clearance) were standardized to allow comparison among studies. A meta-analysis was performed on studies that performed a mixed-effect analysis to calculate weighted mean parameter values and a meta-regression analysis to determine the influence of covariates on parameter values. A pharmacokinetic population model derived from a subset of raw data sets was constructed and compared with the meta-analytical analysis. RESULTS The meta-analysis was performed on 18 studies (11 conducted in healthy adults, 3 in adult patients, and 5 in pediatric patients). Weighted mean volume of distribution was 252 l/70 kg (95% CI, 200 to 304 l/70 kg). Weighted mean clearance was 79 l/h (at 70 kg; 95% CI, 69 to 90 l/h at 70 kg). No effect of covariates was observed; simulations showed that models based on venous sampling showed substantially higher context-sensitive half-times than those based on arterial sampling. The pharmacokinetic model created from 14 raw data sets consisted of one central arterial compartment with two peripheral compartments linked to two venous delay compartments. Simulations showed that the output of the raw data pharmacokinetic analysis and the meta-analysis were comparable. CONCLUSIONS A meta-analytical analysis of ketamine pharmacokinetics was successfully completed despite large heterogeneity in study characteristics. Differences in output of the meta-analytical approach and a combined analysis of 14 raw data sets were small, indicative that the meta-analytical approach gives a clinically applicable approximation of ketamine population parameter estimates and may be used when no raw data sets are available. EDITOR’S PERSPECTIVE
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Kamp J, Jonkman K, van Velzen M, Aarts L, Niesters M, Dahan A, Olofsen E. Pharmacokinetics of ketamine and its major metabolites norketamine, hydroxynorketamine, and dehydronorketamine: a model-based analysis. Br J Anaesth 2020; 125:750-761. [PMID: 32838982 DOI: 10.1016/j.bja.2020.06.067] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/27/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Recent studies show activity of ketamine metabolites, such as hydroxynorketamine, in producing rapid relief of depression-related symptoms and analgesia. To improve our understanding of the pharmacokinetics of ketamine and metabolites norketamine, dehydronorketamine, and hydroxynorketamine, we developed a population pharmacokinetic model of ketamine and metabolites after i.v. administration of racemic ketamine and the S-isomer (esketamine). Pharmacokinetic data were derived from an RCT on the efficacy of sodium nitroprusside (SNP) in reducing the psychotomimetic side-effects of ketamine in human volunteers. METHODS Three increasing i.v. doses of esketamine and racemic ketamine were administered to 20 healthy volunteers, and arterial plasma samples were obtained for measurement of ketamine and metabolites. Subjects were randomised to receive esketamine/SNP, esketamine/placebo, racemic ketamine/SNP, and racemic ketamine/placebo on four separate occasions. The time-plasma concentration data of ketamine and metabolites were analysed using a population compartmental model approach. RESULTS The pharmacokinetics of ketamine and metabolites were adequately described by a seven-compartment model with two ketamine, norketamine, and hydroxynorketamine compartments and one dehydronorketamine compartment with metabolic compartments in-between ketamine and norketamine, and norketamine and dehydronorketamine main compartments. Significant differences were found between S- and R-ketamine enantiomer pharmacokinetics, with up to 50% lower clearances for the R-enantiomers, irrespective of formulation. Whilst SNP had a significant effect on ketamine clearances, simulations showed only minor effects of SNP on total ketamine pharmacokinetics. CONCLUSIONS The model is of adequate quality for use in future pharmacokinetic and pharmacodynamic studies into the efficacy and side-effects of ketamine and metabolites. CLINICAL TRIAL REGISTRATION Dutch Cochrane Center 5359.
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Affiliation(s)
- Jasper Kamp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Kelly Jonkman
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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Kamp J, Van Velzen M, Olofsen E, Boon M, Dahan A, Niesters M. Pharmacokinetic and pharmacodynamic considerations for NMDA-receptor antagonist ketamine in the treatment of chronic neuropathic pain: an update of the most recent literature. Expert Opin Drug Metab Toxicol 2019; 15:1033-1041. [DOI: 10.1080/17425255.2019.1689958] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jasper Kamp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique Van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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An experimental randomized study on the analgesic effects of pharmaceutical-grade cannabis in chronic pain patients with fibromyalgia. Pain 2019; 160:860-869. [PMID: 30585986 PMCID: PMC6430597 DOI: 10.1097/j.pain.0000000000001464] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is Available in the Text. This experimental highly controlled trial in 20 patients with fibromyalgia shows
that the cannabinoid THC, but not CBD, is effective in the treatment of
fibromyalgia pain. In this experimental randomized placebo-controlled 4-way crossover trial, we
explored the analgesic effects of inhaled pharmaceutical-grade cannabis in 20
chronic pain patients with fibromyalgia. We tested 4 different cannabis
varieties with exact knowledge on their
∆9-tetrahydrocannabinol (THC) and cannabidiol (CBD) content:
Bedrocan (22.4-mg THC, <1-mg CBD; Bedrocan International BV, Veendam, the
Netherlands), Bediol (13.4-mg THC, 17.8-mg CBD; Bedrocan International BV,
Veendam, the Netherlands), Bedrolite (18.4-mg CBD, <1-mg THC; Bedrocan
International BV, Veendam, the Netherlands), and a placebo variety without any
THC or CBD. After a single vapor inhalation, THC and CBD plasma concentrations,
pressure and electrical pain thresholds, spontaneous pain scores, and drug high
were measured for 3 hours. None of the treatments had an effect greater than
placebo on spontaneous or electrical pain responses, although more subjects
receiving Bediol displayed a 30% decrease in pain scores compared to placebo
(90% vs 55% of patients, P = 0.01), with spontaneous pain
scores correlating with the magnitude of drug high (ρ = −0.5,
P < 0.001). Cannabis varieties containing THC caused a
significant increase in pressure pain threshold relative to placebo
(P < 0.01). Cannabidiol inhalation increased THC
plasma concentrations but diminished THC-induced analgesic effects, indicative
of synergistic pharmacokinetic but antagonistic pharmacodynamic interactions of
THC and CBD. This experimental trial shows the complex behavior of inhaled
cannabinoids in chronic pain patients with just small analgesic responses after
a single inhalation. Further studies are needed to determine long-term treatment
effects on spontaneous pain scores, THC–CBD interactions, and the role of
psychotropic symptoms on pain relief.
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Pickering G, Morel V, Micallef J. Kétamine et douleur chronique : une revue narrative de son efficacité et sécurité. Therapie 2018; 73:529-539. [DOI: 10.1016/j.therap.2018.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/27/2018] [Accepted: 06/12/2018] [Indexed: 01/19/2023]
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Sleigh J. Can nitric oxide tame the ketamine tiger? Br J Anaesth 2018; 120:890-891. [DOI: 10.1016/j.bja.2018.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 02/14/2018] [Indexed: 11/15/2022] Open
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