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Bentley S, Artin H, Mehaffey E, Liu F, Sojourner K, Bismark A, Printz D, Lee E, Martis B, De Peralta S, Baker D, Mishra J, Ramanathan D. Response to intravenous racemic ketamine after switch from intranasal (S)-ketamine on symptoms of treatment-resistant depression and post-traumatic stress disorder in Veterans: A retrospective case series. Pharmacotherapy 2022; 42:272-279. [PMID: 35122282 PMCID: PMC8934379 DOI: 10.1002/phar.2664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 01/09/2022] [Accepted: 01/11/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Racemic (R,S)-ketamine is a glutamatergic drug with potent and rapid acting antidepressant effects. An intranasal formulation of (S)-ketamine was recently approved by the US Food and Drug Administration (FDA) to be used in individuals with treatment-resistant depression (TRD). There are no data directly comparing outcomes on depression or other comorbidities between these two formulations of ketamine. However, recent meta-analyses have suggested that IV racemic ketamine may be more potent than IN-(S)-ketamine. METHODS We retrospectively analyzed clinical outcomes in 15 Veterans with comorbid TRD and post-traumatic stress disorder (PTSD) who underwent ketamine treatment at the VA San Diego Neuromodulation Clinic. All Veterans included in this analysis were given at least 6 intranasal (IN)-(S)-ketamine treatments prior to switching to treatment with IV racemic ketamine. RESULTS Veterans receiving ketamine treatment ( across both IN-(S)-ketamine and IV-(R,S)-ketamine) showed significant reductions in both the Patient Health Questionnaire-9 (PHQ-9), a self-report scale measuring depression symptoms (rm ANOVA F(14,42) = 12.6, p < 0.0001), and in the PTSD checklist for DSM-5 (PCL-5), a self-report scale measuring PSTD symptoms (rm ANOVA F(13,39) = 5.9, p = 0.006). Post hoc testing revealed that PHQ-9 scores were reduced by an average of 2.4 ± 1.2 compared to baseline after (S)-ketamine treatments (p = 0.1) and by an average of 5.6 ± 1 after IV-ketamine treatments (p = 0.0003) compared to pretreatment baseline scores. PCL-5 scores were reduced by an average of 4.3 ± 3.3 after IN (S)-ketamine treatments (p = 0.6) and 11.8 ± 3.5 after IV-ketamine treatments (p = 0.03) compared to pretreatment baseline scores. CONCLUSIONS This work suggests that off-label IV-(R,S)-ketamine could be considered a reasonable next step in patients who do not respond adequately to the FDA-approved IN-(S)-ketamine. Further double-blinded, randomized controlled trials are warranted to assess whether IV racemic ketamine is more effective than IN-(S)-ketamine.
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Affiliation(s)
- S. Bentley
- Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - H. Artin
- Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - E. Mehaffey
- Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - F. Liu
- Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - K. Sojourner
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161
| | - A. Bismark
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - D. Printz
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - E.E Lee
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - B. Martis
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - S. De Peralta
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - D.G. Baker
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
| | - J. Mishra
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA 92161
| | - D. Ramanathan
- Mental Health Service, VA San Diego Healthcare Syst. (VADHS), San Diego, CA, 92161,Center of Excellence for Stress and Mental Health, VASDHS, San Diego, CA 92161,Dept. of Psychiatry, UC San Diego, La Jolla, CA, 92093
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Shen J, Song C, Lu X, Wen Y, Song S, Yu J, Sun J. The effect of low-dose esketamine on pain and post-partum depression after cesarean section: A prospective, randomized, double-blind clinical trial. Front Psychiatry 2022; 13:1038379. [PMID: 36683972 PMCID: PMC9845877 DOI: 10.3389/fpsyt.2022.1038379] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 12/09/2022] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE To observe and evaluate the effect of a single intravenous injection of low-dose esketamine on post-operative pain and post-partum depression (PPD) in cesarean delivery patients. METHODS A total of 210 patients undergoing elective cesarean delivery under combined spinal-epidural anesthesia were divided into an esketamine group (Group S, n = 105) and a normal saline group (Group L, n = 105) by a random number table. At 5 min after childbirth, patients in the S group were given 0.25 mg/kg esketamine, whereas patients in the L group received an equal volume of saline. The primary outcomes included post-operative pain control according to the Numerical Rating Scale (NRS) and the incidence of PPD according to the Edinburgh Post-partum Depression Scale (EPDS). The secondary outcomes included analgesia-related adverse events and Ramsay sedation scores. RESULTS This clinical study was a prospective, randomized, double-blind trial. A total of 210 patients were enrolled in this study. The NRS pain (cough pain) score was lower in the S group than in the L group at 24 h after surgery (P = 0.016), and there was no significant difference in resting pain and mobilization pain at 4, 8, and 48 h after surgery or resting pain at 24 h after surgery between the two groups. There was no significant difference in the prevalence of PPD between the two groups on the day before delivery, or at the first week, the second week, or the fourth week after childbirth. At 5 min after dosing, the incidence of hallucinations (P < 0.001) and dizziness (P < 0.001) was higher in the S group than in the L group. At 15 min after dosing, the incidence of dizziness (P < 0.001) and nausea (P = 0.011) was higher in the S group than in the L group. The incidence of dizziness (P < 0.001) was higher in the S group than in the L group when leaving the operating room. The Ramsay scores in Group S were lower than in Group L at 5 min (p < 0.001), 15 min (p < 0.001) after dosing and at the time of leaving the operating room (p < 0.001). CONCLUSION In this study, a single intravenous injection of 0.25 mg/kg esketamine did not reduce the incidence of depression at 1, 2, or 4 w post-partum but improved pain during exercise at 24 h post-operatively under the conditions of this clinical trial. CLINICAL TRIAL REGISTRATION [www.chictr.org.cn], identifier [ChiCTR2100054332].
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Affiliation(s)
- Jiahong Shen
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Congzhong Song
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University (Zhejiang Xiaoshan Hospital), Hangzhou, China
| | - Xinlei Lu
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yuxin Wen
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shaobo Song
- Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University (Zhejiang Xiaoshan Hospital), Hangzhou, China
| | - Jing Yu
- Department of Anesthesiology, Affiliated Xiaoshan Hospital, Hangzhou Normal University (Zhejiang Xiaoshan Hospital), Hangzhou, China
| | - Jianliang Sun
- Department of Anesthesiology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Carboni E, Carta AR, Carboni E, Novelli A. Repurposing Ketamine in Depression and Related Disorders: Can This Enigmatic Drug Achieve Success? Front Neurosci 2021; 15:657714. [PMID: 33994933 PMCID: PMC8120160 DOI: 10.3389/fnins.2021.657714] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/31/2021] [Indexed: 12/27/2022] Open
Abstract
Repurposing ketamine in the therapy of depression could well represent a breakthrough in understanding the etiology of depression. Ketamine was originally used as an anesthetic drug and later its use was extended to other therapeutic applications such as analgesia and the treatment of addiction. At the same time, the abuse of ketamine as a recreational drug has generated a concern for its psychotropic and potential long-term effects; nevertheless, its use as a fast acting antidepressant in treatment-resistant patients has boosted the interest in the mechanism of action both in psychiatry and in the wider area of neuroscience. This article provides a comprehensive overview of the actions of ketamine and intends to cover: (i) the evaluation of its clinical use in the treatment of depression and suicidal behavior; (ii) the potential use of ketamine in pediatrics; (iii) a description of its mechanism of action; (iv) the involvement of specific brain areas in producing antidepressant effects; (v) the potential interaction of ketamine with the hypothalamic-pituitary-adrenal axis; (vi) the effect of ketamine on neuronal transmission in the bed nucleus of stria terminalis and on its output; (vii) the evaluation of any gender-dependent effects of ketamine; (viii) the interaction of ketamine with the inflammatory processes involved in depression; (ix) the evaluation of the effects observed with single or repeated administration; (x) a description of any adverse or cognitive effects and its abuse potential. Finally, this review attempts to assess whether ketamine's use in depression can improve our knowledge of the etiopathology of depression and whether its therapeutic effect can be considered an actual cure for depression rather than a therapy merely aimed to control the symptoms of depression.
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Affiliation(s)
- Ezio Carboni
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Anna R. Carta
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Elena Carboni
- Unit of Paediatrics, ASST Cremona Maggiore Hospital, Cremona, Italy
| | - Antonello Novelli
- Department of Psychology and University Institute of Biotechnology of Asturias, University of Oviedo, Oviedo, Spain
- Sanitary Institute of the Princedom of Asturias, Oviedo, Spain
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Abstract
An intranasal formulation of esketamine, the S enantiomer of ketamine, in conjunction with an oral antidepressant, has been approved by the FDA for treating treatment-resistant major depressive disorder (TRD) in 2019, almost 50 years after it was approved as an intravenous anesthetic. In contrast to traditional antidepressants, ketamine shows a rapid (within 2 h) and sustained (∼7 days) antidepressant effect and has significant positive effects on antisuicidal ideation. Ketamine's antidepressant mechanism is predominantly mediated by the N-methyl-d-aspartate receptor (NMDA) receptor, although NMDA-independent mechanisms are not ruled out. At the neurocircuitry level, ketamine affects the brain's reward and mood circuitry located in the corticomesolimbic structures involving the hippocampus, nucleus accumbens, and prefrontal cortex. Repurposing of ketamine for treating TRD provided a new understanding of the pathophysiology of depression, a paradigm shift from monoamine to glutamatergic neurotransmission, thus making it a unique tool to investigate the brain and its complex neurocircuitries.
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Affiliation(s)
- Joydip Das
- Department of Pharmacological & Pharmaceutical Sciences, College of Pharmacy, University of Houston, Houston, Texas 77204, United States
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Hashimoto K. Rapid-acting antidepressant ketamine, its metabolites and other candidates: A historical overview and future perspective. Psychiatry Clin Neurosci 2019; 73:613-627. [PMID: 31215725 PMCID: PMC6851782 DOI: 10.1111/pcn.12902] [Citation(s) in RCA: 224] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 05/28/2019] [Accepted: 06/06/2019] [Indexed: 12/11/2022]
Abstract
Major depressive disorder (MDD) is one of the most disabling psychiatric disorders. Approximately one-third of the patients with MDD are treatment resistant to the current antidepressants. There is also a significant therapeutic time lag of weeks to months. Furthermore, depression in patients with bipolar disorder (BD) is typically poorly responsive to antidepressants. Therefore, there exists an unmet medical need for rapidly acting antidepressants with beneficial effects in treatment-resistant patients with MDD or BD. Accumulating evidence suggests that the N-methyl-D-aspartate receptor (NMDAR) antagonist ketamine produces rapid and sustained antidepressant effects in treatment-resistant patients with MDD or BD. Ketamine is a racemic mixture comprising equal parts of (R)-ketamine (or arketamine) and (S)-ketamine (or esketamine). Because (S)-ketamine has higher affinity for NMDAR than (R)-ketamine, esketamine was developed as an antidepressant. On 5 March 2019, esketamine nasal spray was approved by the US Food and Drug Administration. However, preclinical data suggest that (R)-ketamine exerts greater potency and longer-lasting antidepressant effects than (S)-ketamine in animal models of depression and that (R)-ketamine has less detrimental side-effects than (R,S)-ketamine or (S)-ketamine. In this article, the author reviews the historical overview of the antidepressant actions of enantiomers of ketamine and its major metabolites norketamine and hydroxynorketamine. Furthermore, the author discusses the other potential rapid-acting antidepressant candidates (i.e., NMDAR antagonists and modulators, low-voltage-sensitive T-type calcium channel inhibitor, potassium channel Kir4.1 inhibitor, negative modulators of γ-aminobutyric acid, and type A [GABAA ] receptors) to compare them with ketamine. Moreover, the molecular and cellular mechanisms of ketamine's antidepressant effects are discussed.
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Affiliation(s)
- Kenji Hashimoto
- Division of Clinical Neuroscience, Chiba University Center for Forensic Mental Health, Chiba, Japan
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Johnson JW, Glasgow NG, Povysheva NV. Recent insights into the mode of action of memantine and ketamine. Curr Opin Pharmacol 2014; 20:54-63. [PMID: 25462293 DOI: 10.1016/j.coph.2014.11.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/12/2014] [Accepted: 11/13/2014] [Indexed: 01/21/2023]
Abstract
The clinical benefits of the glutamate receptor antagonists memantine and ketamine have helped sustain optimism that glutamate receptors represent viable targets for development of therapeutic drugs. Both memantine and ketamine antagonize N-methyl-D-aspartate receptors (NMDARs), a glutamate receptor subfamily, by blocking the receptor-associated ion channel. Although many of the basic characteristics of NMDAR inhibition by memantine and ketamine appear similar, their effects on humans and to a lesser extent on rodents are strongly divergent. Some recent research suggests that preferential inhibition by memantine and ketamine of distinct NMDAR subpopulations may contribute to the drugs' differential clinical effects. Here we review studies that shed light on possible explanations for differences between the effects of memantine and ketamine.
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Affiliation(s)
- Jon W Johnson
- Department of Neuroscience and Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15260, USA.
| | - Nathan G Glasgow
- Department of Neuroscience and Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Nadezhda V Povysheva
- Department of Neuroscience and Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Kotermanski SE, Johnson JW, Thiels E. Comparison of behavioral effects of the NMDA receptor channel blockers memantine and ketamine in rats. Pharmacol Biochem Behav 2013; 109:67-76. [PMID: 23665480 DOI: 10.1016/j.pbb.2013.05.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 04/27/2013] [Accepted: 05/02/2013] [Indexed: 01/07/2023]
Abstract
Memantine and ketamine block N-methyl-D-aspartate (NMDA) receptors with similar affinity and kinetics, yet their behavioral consequences differ: e.g., memantine is used to alleviate symptoms of Alzheimer's disease, whereas ketamine reproduces symptoms of schizophrenia. The two drugs exhibit different pharmacokinetics, which may play a principal role in their differential behavioral effects. To gain insight into the drugs' behavioral consequences, we treated adult male rats acutely with varying doses (0-40 mg/kg i.p.) of memantine or ketamine and assessed exploratory behavior and spatial working memory. To examine the importance of pharmacokinetics, we assessed behavior either 15 or 45 min after drug administration. Both drugs decreased ambulation, fine movements, and rearing at the beginning of the exploratory activity test; however, at the end of the test, high doses of only memantine increased ambulation and fine movements. High doses of both drugs disrupted spontaneous alternation, a measure of working memory, but high doses of only memantine elicited perseverative behavior. Surprisingly, ketamine's effects were influenced by the delay between drug administration and testing no more frequently than were memantine's. Our findings show that, regardless of test delay, memantine and ketamine evoke similar behavioral effects at lower doses, consistent with NMDA receptors being both drugs' principal site of action, but can have divergent effects at higher doses. Our results suggest that the divergence of memantine's and ketamine's behavioral consequences is likely to result from differences in mechanisms of NMDA receptor antagonism or actions at other targets.
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Affiliation(s)
- Shawn E Kotermanski
- Department of Neuroscience, University of Pittsburgh, Pittsburgh, PA 15260, USA
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Abstract
Ketamine has important anesthetic, analgesic, and psychotropic actions. It is widely believed that NMDA receptor inhibition accounts for ketamine actions, but there remains a dearth of behavioral evidence to support this hypothesis. Here, we present an alternative, behaviorally relevant molecular substrate for anesthetic effects of ketamine: the HCN1 pacemaker channels that underlie a neuronal hyperpolarization-activated cationic current (I(h)). Ketamine caused subunit-specific inhibition of recombinant HCN1-containing channels and neuronal I(h) at clinically relevant concentrations; the channels were more potently inhibited by S-(+)-ketamine than racemic ketamine, consistent with anesthetic actions of the compounds. In cortical pyramidal neurons from wild-type, but not HCN1 knock-out mice, ketamine induced membrane hyperpolarization and enhanced dendritosomatic synaptic coupling; both effects are known to promote cortical synchronization and support slow cortical rhythms, like those accompanying anesthetic-induced hypnosis. Accordingly, we found that the potency for ketamine to provoke a loss-of-righting reflex, a behavioral correlate of hypnosis, was strongly reduced in HCN1 knock-out mice. In addition, hypnotic sensitivity to two other intravenous anesthetics in HCN1 knock-out mice matched effects on HCN1 channels; propofol selectively inhibited HCN1 channels and propofol sensitivity was diminished in HCN1 knock-out mice, whereas etomidate had no effect on HCN1 channels and hypnotic sensitivity to etomidate was unaffected by HCN1 gene deletion. These data advance HCN1 channels as a novel molecular target for ketamine, provide a plausible neuronal mechanism for enhanced cortical synchronization during anesthetic-induced hypnosis and suggest that HCN1 channels might contribute to other unexplained actions of ketamine.
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