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Simons P, Olofsen E, van Velzen M, van Lemmen M, van Dasselaar T, Mohr P, Hammes F, van der Schrier R, Niesters M, Dahan A. S-Ketamine oral thin film—Part 2: Population pharmacodynamics of S-ketamine, S-norketamine and S-hydroxynorketamine. FRONTIERS IN PAIN RESEARCH 2022; 3:946487. [PMID: 36034750 PMCID: PMC9402896 DOI: 10.3389/fpain.2022.946487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/05/2022] [Indexed: 12/17/2022] Open
Abstract
Ketamine is a versatile drug used for many indications and is administered via various routes. Here, we report on the pharmacodynamics of sublingual and buccal fast-dissolving oral-thin-films that contain 50 mg of S-ketamine in a population of healthy male and female volunteers. Twenty volunteers received one or two 50 mg S-ketamine oral thin films in a crossover design, placed for 10 min sublingually (n = 15) or buccally (n = 5). The following measurements were made for 6 h following the film placement: antinociception using three distinct pain assay; electrical, pressure, and heat pain, and drug high on an 11-point visual analog scale. Blood samples were obtained for the measurement of plasma S-ketamine, S-norketamine, and S-hydroxynorketamine concentrations. A population pharmacodynamic analysis was performed in NONMEM to construct a pharmacodynamic model of S-ketamine and its metabolites. P-values < 0.01 were considered significant. The sublingual and buccal 50 and 100 mg S-ketamine oral thin films were antinociceptive and produced drug high with effects lasting 2–6 h, although a clear dose-response relationship for antinociception could not be established. The effects were solely related to the parent compound with no contribution from S-norketamine or S-hydroxynorketamine. S-ketamine potency was lower for antinociception (C50 ranging from 1.2 to 1.7 nmol/mL) than for drug high (C50 0.3 nmol/ml). The onset/offset of effect as defined by the blood-effect-site equilibration half-life did not differ among endpoints and ranged from 0 to 5 min. In conclusion, the 50-mg S-ketamine oral thin film was safe and produced long-term antinociception in all three nociceptive assays with side effects inherent to the use of ketamine. The study was registered at the trial register of the Dutch Cochrane Center (www.trialregister.nl) under identifier NL9267 and the European Union Drug Regulating Authorities Clinical Trials (EudraCT) database under number 2020-005185-33.
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Affiliation(s)
- Pieter Simons
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Tom van Dasselaar
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Patrick Mohr
- LTS Lohmann Therapie-Systeme AG, Andernach, Germany
| | | | | | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Albert Dahan
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Moore E, Mayes R, Harkin M, Miller JL, Johnson PN. Extended Duration Ketamine Infusions in Critically Ill Children: A Case Report and Review of the Literature. J Pediatr Intensive Care 2020; 10:221-227. [PMID: 34395041 DOI: 10.1055/s-0040-1713144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022] Open
Abstract
Ketamine is an N -methyl-D-aspartate receptor antagonist that has been used as an adjunct analgesic and sedative in critically ill children. Previous reports noted that ketamine has been used for a variable duration of 12 to 408 hours for this indication. We report on the use of ketamine infusions for >720 hours as a second-line sedative in addition to an opioid and dexmedetomidine infusion in a 2-month old and 17-month old. The purpose of this case report and review of the literature is to highlight the prolonged ketamine exposure of these two patients and to provide awareness to clinicians on the potential of withdrawal with extended ketamine administration. These children were started on initials doses of 5 and 15 µg/kg/min and titrated to peak doses of 20 and 25 µg/kg/min, respectively. They were continued for a total of 987 and 792 hours, respectively. No adverse events were noted during the ketamine infusions. One patient developed possible withdrawal symptoms 17 hours after ketamine discontinuation despite tapering of the infusion. These symptoms resolved with administration of as needed intravenous opioids and benzodiazepines, and the agitation normalized within 24 hours after ketamine discontinuation. Clinicians should consider tapering ketamine infusions in children receiving >72 hours of a continuous infusion by 5 µg/kg/min every 8 to 12 hours. Patients should be monitored for potential withdrawal symptoms including anxiety, allodynia, hyperalgesia, sweating, and drowsiness.
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Affiliation(s)
- Eszter Moore
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Rebecca Mayes
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Maura Harkin
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States.,Department of Pharmacy, Division of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Jamie L Miller
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States.,Department of Pharmacy, Division of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
| | - Peter N Johnson
- University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States.,Department of Pharmacy, Division of Clinical and Administrative Sciences, University of Oklahoma College of Pharmacy, Oklahoma City, Oklahoma, United States
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Brady B, Mulqueen L, Cunningham J. Twelve Years in Pain: Case Report on the Management of Complex Pain in Syringomyelia. J Pain Symptom Manage 2020; 59:e1-e3. [PMID: 31775022 DOI: 10.1016/j.jpainsymman.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Bernadette Brady
- Academic Department of Palliative Medicine, Our Lady's Hospice and Care Services, Dublin, Ireland; Blackrock Hospice, Our Lady's Hospice and Care Services, Blackrock, Co. Dublin, Ireland.
| | - Laura Mulqueen
- Blackrock Hospice, Our Lady's Hospice and Care Services, Blackrock, Co. Dublin, Ireland
| | - Joan Cunningham
- Blackrock Hospice, Our Lady's Hospice and Care Services, Blackrock, Co. Dublin, Ireland; Wicklow Specialist Palliative Care Services, Primary Care Centre, Wicklow, Ireland
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Bell RF, Kalso EA. Ketamine for pain management. Pain Rep 2018; 3:e674. [PMID: 30534625 PMCID: PMC6181464 DOI: 10.1097/pr9.0000000000000674] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 06/19/2018] [Accepted: 06/21/2018] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is Available in the Text.
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Affiliation(s)
- Rae Frances Bell
- Regional Centre of Excellence in Palliative Care, Haukeland University Hospital, Bergen, Norway
| | - Eija Anneli Kalso
- Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Pain Clinic, Helsinki University Hospital, Helsinki, Finland
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Abstract
The efficacy of the N-methyl-D-aspartate receptor antagonist ketamine as an analgesic agent is still under debate, especially for indications such as chronic pain. To understand the efficacy of ketamine for relief of pain, we performed a literature search for relevant narrative and systematic reviews and meta-analyses. We retrieved 189 unique articles, of which 29 were deemed appropriate for use in this review. Ketamine treatment is most effective for relief of postoperative pain, causing reduced opioid consumption. In contrast, for most other indications (that is, acute pain in the emergency department, prevention of persistent postoperative pain, cancer pain, and chronic non-cancer pain), the efficacy of ketamine is limited. Ketamine's lack of analgesic effect was associated with an increase in side effects, including schizotypical effects.
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Affiliation(s)
- Kelly Jonkman
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Tine van de Donk
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Anesthesia & Pain Research Unit, Leiden University Medical Center, Leiden, Netherlands
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Abstract
BACKGROUND This is an update of a review first published in 2003 and updated in 2012.Ketamine is a commonly used anaesthetic agent, and in subanaesthetic doses is also given as an adjuvant to opioids for the treatment of refractory cancer pain, when opioids alone or in combination with appropriate adjuvant analgesics prove to be ineffective. Ketamine is known to have psychomimetic (including hallucinogenic), urological, and hepatic adverse effects. OBJECTIVES To determine the effectiveness and adverse effects of ketamine as an adjuvant to opioids for refractory cancer pain in adults. SEARCH METHODS For this update, we searched MEDLINE (OVID) to December 2016. We searched CENTRAL (CRSO), Embase (OVID) and two clinical trial registries to January 2017. SELECTION CRITERIA The intervention considered by this review was the addition of ketamine, given by any route of administration, in any dose, to pre-existing opioid treatment given by any route and in any dose, compared with placebo or active control. We included studies with a group size of at least 10 participants who completed the trial. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the search results and performed 'Risk of bias' assessments. We aimed to extract data on patient-reported pain intensity, total opioid consumption over the study period; use of rescue medication; adverse events; measures of patient satisfaction/preference; function; and distress. We also assessed participant withdrawal (dropout) from trial. We assessed the quality of the evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). MAIN RESULTS One new study (185 participants) was identified by the updated search and included in the review. We included a total of three studies in this update.Two small studies, both with cross-over design, with 20 and 10 participants respectively, were eligible for inclusion in the original review. One study with 20 participants examined the addition of intrathecal ketamine to intrathecal morphine, compared with intrathecal morphine alone. The second study with 10 participants examined the addition of intravenous ketamine bolus in two different doses to ongoing morphine therapy, compared with placebo. Both of these studies reported reduction in pain intensity and reduction in morphine requirements when ketamine was added to opioid for refractory cancer pain. The new study identified by the updated search had a parallel group design and 185 participants. This placebo-controlled study examined rapid titration of subcutaneous ketamine to high dose (500 mg) in participants who were using different opioids. There were no differences between groups for patient-reported pain intensity.Pooling of the data from the three included trials was not appropriate because of clinical heterogeneity.The study examining intrathecal drug administration reported no adverse events related to ketamine. In the study using intravenous bolus administration, ketamine caused hallucinations in four of 10 participants. In the rapid dose escalation/high-dose subcutaneous ketamine study, there was almost twice the incidence of adverse events in the ketamine group, compared to the placebo group, with the most common adverse events being needle site irritation and cognitive disturbance. Two serious adverse events (bradyarrhythmia and cardiac arrest) thought to be related to ketamine were also reported in this trial.For all three studies there was an unclear risk of bias overall. Using GRADE, we judged the quality of the evidence to be very low due to study limitations and imprecision due to the small number of participants in all comparisons. AUTHORS' CONCLUSIONS Current evidence is insufficient to assess the benefits and harms of ketamine as an adjuvant to opioids for the relief of refractory cancer pain. The evidence was of very low quality, meaning that it does not provide a reliable indication of the likely effect, and the likelihood that the effect will be substantially different is high. Rapid dose escalation of ketamine to high dose (500 mg) does not appear to have clinical benefit and may be associated with serious adverse events. More randomised controlled trials (RCTs) examining specific low-dose ketamine clinical regimens in current use are needed.
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Affiliation(s)
- Rae Frances Bell
- Haukeland University HospitalRegional Centre of Excellence in Palliative CareBergenNorway
| | - Christopher Eccleston
- University of BathCentre for Pain ResearchClaverton DownBathUK
- Ghent UniversityDepartment of Clinical and Health PsychologyGhentBelgium
| | - Eija A Kalso
- Helsinki University and Helsinki University HospitalDepartment of Anaesthesia, Intensive Care and Pain MedicineHelsinkiFinland
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Busse J, Phillips L, Schechter W. Long-Term Intravenous Ketamine for Analgesia in a Child with Severe Chronic Intestinal Graft versus Host Disease. Case Rep Anesthesiol 2015; 2015:834168. [PMID: 26779350 PMCID: PMC4686632 DOI: 10.1155/2015/834168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 11/29/2015] [Indexed: 11/18/2022] Open
Abstract
Ketamine is reported to be an effective adjuvant to opioids in the treatment of refractory cancer pain; however, the use of high doses of ketamine for extended periods in pediatric patients has not been described. We present a five-year-old male with grade IV intestinal GVHD whose abdominal pain required both hydromorphone and ketamine for a period of over four months. There was no evidence of hepatotoxicity, hemorrhagic cystitis, or other adverse effects. Possible withdrawal symptoms were mild and were readily mitigated by gradually weaning ketamine.
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Affiliation(s)
- Jennifer Busse
- Anesthesiology, Morgan Stanley Children's Hospital at Columbia University, New York, NY 10032, USA
| | - Leroy Phillips
- Anesthesiology, New York University Langone Medical Center, New York, NY 10016, USA
| | - William Schechter
- Anesthesiology and Pediatrics, Morgan Stanley Children's Hospital at Columbia University, New York, NY 10032, USA
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Affiliation(s)
- Rachel Quibell
- Newcastle upon Tyne Hospitals Foundation Trust, Newcastle, United Kingdom
| | - Marie Fallon
- University of Edinburgh, Edinburgh, United Kingdom
| | - Mary Mihalyo
- Mylan School of Pharmacy, Duquesne University, Pittsburgh, Pennsylvania, USA
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Walgren JL, Carfagna MA, Koger D, Sgro M, Kallman MJ. Withdrawal assessment following subchronic oral ketamine administration in Cynomolgus macaques. Drug Dev Res 2014; 75:162-71. [PMID: 24648280 DOI: 10.1002/ddr.21168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 01/20/2014] [Indexed: 01/05/2023]
Abstract
Recently there is increased regulatory interest in the assessment of physical dependence and withdrawal as part of the safety assessment for novel therapeutic entities. Choosing appropriate and sensitive parameters to detect withdrawal syndromes, and relevant positive control comparator drugs that can be administered in the same manner as the test agent, are critical study design elements. Pilot studies to determine the effects of oral ketamine in cynomolgus monkeys during, and following cessation of treatment, were explored. Detailed behavioral observations (both remote and interactive), food consumption, and body weight and temperature, were assessed during the dose-ranging, repeat dose (5 or 14 days), and withdrawal phases (3 or 5 days). Doses explored during dose-ranging included 20, 40, 100, or 200 mg/kg ketamine; subsequent withdrawal assessments were conducted following repeat dosing of 150 mg/kg. In the 14-day dosing study, exposure to ketamine and norketamine was assessed following 8 days of dosing. Administration of 150 mg/kg ketamine produced decreased activity, loss of balance, ataxia, hunched posture, nystagmus, lateral recumbence, and changes in alertness levels during dosing phases. When ketamine was withdrawn, increased reactivity, increased activity, and stereotypic behaviors were demonstrated that were absent during baseline or the dosing phase of the studies.
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Affiliation(s)
- Jennie L Walgren
- Non-Clinical Safety Assessment, Eli Lilly and Company, Indianapolis, IN, 46285, USA
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11
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Abstract
BACKGROUND This is an update of the original review published in Issue 1, 2003. Ketamine is a commonly used anaesthetic agent, and in subanaesthetic doses is also given as an adjuvant to opioids for the treatment of cancer pain, particularly when opioids alone prove to be ineffective. Ketamine is known to have psychotomimetic (including hallucinogenic), urological and hepatic adverse effects. OBJECTIVES To determine the effectiveness and adverse effects of ketamine as an adjuvant to opioids in the treatment of cancer pain. SEARCH METHODS Studies were originally identified from MEDLINE (1966 to 2002), EMBASE (1980 to 2002), CancerLit (1966 to 2002), The Cochrane Library (Issue 1, 2001); by handsearching reference lists from review articles, trials, and chapters from standard textbooks on pain and palliative care. The manufacturer of ketamine (Pfizer Parke-Davis) provided search results from their in-house database, PARDLARS.An improved and updated search of the following was performed in May 2012: CENTRAL, MEDLINE & OVID MEDLINE R, EMBASE. SELECTION CRITERIA Randomized controlled trials (RCTs) of adult patients with cancer and pain being treated with an opioid, and receiving either ketamine (any dose and any route of administration) or placebo or an active control. Studies having a group size of at least 10 participants who completed the trial. DATA COLLECTION AND ANALYSIS Two independent review authors identified four RCTs for possible inclusion in the review, and 32 case studies/case series reports. Quality and validity assessment was performed by three independent review authors, and two RCTs were excluded because of inappropriate study design. Patient-reported pain intensity and pain relief was assessed using visual analogue scales (VAS), verbal rating scales or other validated scales, and adverse effects data were collated. For the update three RCTs were identified for possible inclusion in the review. MAIN RESULTS Three new studies were identified by the updated search. All three were excluded from the review. Two studies were eligible for inclusion in the original review and both concluded that ketamine improves the effectiveness of morphine in the treatment of cancer pain. However, pooling of the data was not appropriate because of the small total number of participants (30), and the presence of clinical heterogeneity. Some patients experienced hallucinations on both ketamine plus morphine and morphine alone and were treated successfully with diazepam. No other serious adverse effects were reported. AUTHORS' CONCLUSIONS Since the last version of this review three new studies were identified but excluded from the review. Current evidence is insufficient to assess the benefits and harms of ketamine as an adjuvant to opioids for the relief of cancer pain. More RCTs are needed.
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Affiliation(s)
- Rae F Bell
- Centre for PainManagement and Palliative Care & Regional Centre for Excellence in Palliative Care, Haukeland University Hospital,Bergen, Norway.
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12
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Olofsen E, Noppers I, Niesters M, Kharasch E, Aarts L, Sarton E, Dahan A. Estimation of the contribution of norketamine to ketamine-induced acute pain relief and neurocognitive impairment in healthy volunteers. Anesthesiology 2012; 117:353-64. [PMID: 22692377 DOI: 10.1097/aln.0b013e31825b6c91] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The N-methyl-D-aspartate receptor antagonist ketamine is metabolized in the liver into its active metabolite norketamine. No human data are available on the relative contribution of norketamine to ketamine-induced analgesia and side effects. One approach to assess the ketamine and norketamine contributions is by measuring the ketamine effect at varying ketamine and norketamine plasma concentrations using the CYP450 inducer rifampicin. METHODS In 12 healthy male volunteers the effect of rifampicin versus placebo pretreatment on S-ketamine-induced analgesia and cognition was quantified; the S-ketamine dosage was 20 mg/h for 2 h. The relative ketamine and norketamine contribution to effect was estimated using a linear additive population pharmacokinetic-pharmacodynamic model. RESULTS S-ketamine produced significant analgesia, psychotropic effects (drug high), and cognitive impairment (including memory impairment and reduced psychomotor speed, reaction time, and cognitive flexibility). Modeling revealed a negative contribution of S-norketamine to S-ketamine- induced analgesia and absence of contribution to cognitive impairment. At ketamine and norketamine effect concentrations of 100 ng/ml and 50 ng/ml, respectively, the ketamine contribution to analgesia is -3.8 cm (visual analog pain score) versus a contribution of norketamine of +1.5 cm, causing an overall effect of -2.3 cm. The blood-effect site equilibration half-life ranged from 0 (cognitive flexibility) to 11.8 (pain intensity) min and was 6.1 min averaged across all endpoints. CONCLUSIONS This first observation that norketamine produces effects in the opposite direction of ketamine requires additional proof. It can explain the observation of ketamine-related excitatory phenomena (such as hyperalgesia and allodynia) upon the termination of ketamine infusions.
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Affiliation(s)
- Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Niesters M, Dahan A. Pharmacokinetic and pharmacodynamic considerations for NMDA receptor antagonists in the treatment of chronic neuropathic pain. Expert Opin Drug Metab Toxicol 2012; 8:1409-17. [DOI: 10.1517/17425255.2012.712686] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Affiliation(s)
- Rachel Quibell
- Newcastle upon Tyne Hospitals Foundation Trust, Newcastle, United Kingdom
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15
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Effect of ketamine on endogenous pain modulation in healthy volunteers. Pain 2011; 152:656-663. [PMID: 21237568 DOI: 10.1016/j.pain.2010.12.015] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2010] [Revised: 10/21/2010] [Accepted: 12/09/2010] [Indexed: 01/10/2023]
Abstract
Inhibitory and facilitatory descending pathways, originating at higher central nervous system sites, modulate activity of dorsal horn nociceptive neurons, and thereby influence pain perception. Dysfunction of inhibitory pain pathways or a shift in the balance between pain facilitation and pain inhibition has been associated with the development of chronic pain. The N-methyl-d-aspartate receptor antagonist ketamine has a prolonged analgesic effect in chronic pain patients. This effect is due to desensitization of sensitized N-methyl-d-aspartate receptors. Additionally, ketamine may modulate or enhance endogenous inhibitory control of pain perception. Diffuse noxious inhibitory control (DNIC) and offset analgesia (OA) are 2 mechanisms involved in descending inhibition. The present study investigates the effect of a ketamine infusion on subsequent DNIC and OA responses to determine whether ketamine has an influence on descending pain control. Ten healthy subjects (4 men/6 women) received a 1-hour placebo or S(+)-ketamine (40mg per 70kg) infusion on 2 separate occasions in random order. Upon the termination of the infusion, DNIC and OA responses were obtained. After placebo treatment, significant descending inhibition of pain responses was present for DNIC and OA. In contrast, after ketamine infusion, no DNIC was observed, but rather a significant facilitatory pain response (P<0.01); the OA response remained unchanged. These findings suggest that the balance between pain inhibition and pain facilitation was shifted by ketamine towards pain facilitation. The absence of an effect of ketamine on OA indicates differences in the mechanisms and neurotransmitter influences between OA and DNIC. Diffuse noxious inhibitory control responses following a 1-hour low-dose ketamine treatment displayed facilitation of pain in response to experimental noxious thermal stimulation.
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Visser E, Schug SA. The role of ketamine in pain management. Biomed Pharmacother 2006; 60:341-8. [PMID: 16854557 DOI: 10.1016/j.biopha.2006.06.021] [Citation(s) in RCA: 172] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2006] [Accepted: 06/12/2006] [Indexed: 01/21/2023] Open
Abstract
Ketamine is a dissociative anaesthetic; its mechanism of action is primarily an antagonism of the N-methyl-D-aspartate (NMDA) receptor. The role of ketamine, in particular in lower sub-anaesthetic doses, has recently gained increasing interest in pain management. It has been studied in a considerable number of trials and analysed in meta-analyses and systematic reviews. Based on these data, the primary role of ketamine in such low doses is as an 'anti-hyperalgesic', 'anti-allodynic' or 'tolerance-protective' agent. It therefore has a role in the treatment of opioid resistant or 'pathological' pain (central sensitisation with hyperalgesia or allodynia, opioid induced hyperalgesia, neuropathic pain) rather than as an 'analgesic' in its own right. Low dose ketamine also has 'preventive analgesia' properties. Furthermore, in higher doses it provides effective and safe sedation and analgesia for painful procedures. The place of ketamine in the treatment of chronic pain and the effects of long-term medicinal use remain unclear.
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Affiliation(s)
- E Visser
- Department of Anaesthesia and Pain Medicine, Royal Perth Hospital, and University of Western Australia, School of Medicine and Pharmacology, Perth, WA 6847, Australia
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17
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Friedman R, Kamel I, Perez C, Hamada A. Severe intraoperative hypertension and opioid-resistant postoperative pain in a methadone-treated patient. THE JOURNAL OF PAIN 2003; 4:289-90. [PMID: 14622699 DOI: 10.1016/s1526-5900(03)00555-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Patients who are treated with methadone present challenges for the anesthesiologist. We report the untoward effects of rapid preoperative methadone tapering on the operative and perioperative course of a patient who required emergency surgery. The patient's exaggerated stress response to surgery and severe intractable postoperative pain might have resulted from unrecognized methadone withdrawal. Continuation of methadone treatment in patients who have surgery may prevent exaggerated intraoperative hemodynamic responses to surgical stimuli and unnecessary postoperative suffering.
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Affiliation(s)
- Robert Friedman
- Department of Anesthesiology, Temple University Hospital, Philadelphia, Pennsylvania 19140, USA
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18
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Bell RF, Eccleston C, Kalso E. Ketamine as adjuvant to opioids for cancer pain. A qualitative systematic review. J Pain Symptom Manage 2003; 26:867-75. [PMID: 12967737 DOI: 10.1016/s0885-3924(03)00311-7] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ketamine is increasingly being used as an adjuvant to opioids in the treatment of refractory cancer pain. This systematic review examines the available evidence. Randomized, controlled trials, with or without crossover, were included. Studies were identified from MEDLINE, EMBASE, CANCERLIT, the Cochrane Library, handsearched reference lists from review articles and chapters from standard textbooks on pain and palliative care and reference lists from papers retrieved. Four randomized, controlled studies were identified. Two were excluded due to poor quality. Both included studies concluded that ketamine improves morphine treatment in cancer pain. Quantitative meta-analysis was not possible. The available evidence is not sufficient to conclude that ketamine improves the effectiveness of opioid treatment in cancer pain. High quality, randomized, controlled trials with larger numbers of patients and standardized, clinically relevant routes of administration of ketamine are needed.
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Affiliation(s)
- Rae F Bell
- Pain Clinic, Department of Anesthesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway
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Al-Shahri MZ, Molina EH, Oneschuk D. Medication-focused approach to total pain: poor symptom control, polypharmacy, and adverse reactions. Am J Hosp Palliat Care 2003; 20:307-10. [PMID: 12911076 DOI: 10.1177/104990910302000414] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Neuropathic pain, known to have poor opioid response, can be difficult to control. Although several classes of adjuvant medications are believed to be of benefit in managing neuropathic pain, they have potential side effects that occasionally outweigh their benefits. The psychospiritual suffering of patients with advanced cancer may heighten the distress associated with physical symptoms. If undiagnosed, this may lead to increases in dose and the number of medications administered in the hope of better symptom control. This case report describes the successful interdisciplinary management of an advanced cancer patient whose multiple drug therapy had added to rather than alleviated his distress by causing more side effects than symptom relief.
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Affiliation(s)
- Mohammad Zafir Al-Shahri
- Palliative Medicine Consultant, Department of Oncology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Abstract
BACKGROUND Ketamine is a commonly used anaesthetic agent, and in subanaesthetic doses is also given as an adjuvant to opioids for the treatment of cancer pain, particularly when opioids alone prove to be ineffective. Ketamine is known to have hallucinogenic side effects. To date no systematic review of the benefits and harms of adjuvant ketamine for cancer pain has been undertaken. OBJECTIVES To determine the effectiveness and adverse effects of ketamine as an adjuvant to opioids in the treatment of cancer pain. SEARCH STRATEGY Studies were identified from MEDLINE (1966-2001), EMBASE (1980-2001), CancerLit (1966-2001), the Cochrane Library (Issue 1, 2001); by handsearching reference lists from review articles, trials, and chapters from standard textbooks on pain and palliative care. The manufacturer of ketamine (Pfizer Parke-Davis) provided search results from their in-house database, PARDLARS. SELECTION CRITERIA RCTs of adult patients with cancer and pain being treated with an opioid, and receiving either ketamine (any dose and any route of administration) or placebo or an active control. DATA COLLECTION AND ANALYSIS Two independent reviewers identified four RCTs for possible inclusion in the review, and 32 case studies/case series reports. Quality and validity assessment was performed by three independent reviewers, and two RCTs were excluded because of inappropriate study design. Patient reported pain intensity and pain relief was assessed using visual analog scales, verbal rating scales or other validated scales, and adverse effects data were collated. MAIN RESULTS Two trials were eligible for inclusion in the review and both concluded that ketamine improves the effectiveness of morphine in the treatment of cancer pain. However, pooling of the data was not appropriate because of the small total number of patients (30), and the presence of clinical heterogeneity. Some patients experienced hallucinations on both ketamine plus morphine and morphine alone and were treated successfully with diazepam. No other serious adverse effects were reported. REVIEWER'S CONCLUSIONS Current evidence is insufficient to assess the benefits and harms of ketamine as an adjuvant to opioids for the relief of cancer pain. More randomized controlled trials are needed.
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Affiliation(s)
- R Bell
- Pain Clinic, Haukeland University Hospital, Bergen, Norway, N-5021.
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