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Lohela TJ, Poikola S, Backmansson D, Lapatto-Reiniluoto O, Backman JT, Olkkola KT, Lilius TO. Influence of Intravenous S-Ketamine on the Pharmacokinetics of Oral Morphine in Healthy Volunteers. Anesth Analg 2024; 138:598-606. [PMID: 37733945 PMCID: PMC10852043 DOI: 10.1213/ane.0000000000006640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Subanesthetic ketamine may reduce perioperative consumption of opioids. We studied whether intravenous S-ketamine alters the pharmacokinetics of oral morphine in healthy volunteers. METHODS In this paired, randomized, double-blind, crossover trial, 12 participants under a 2-hour intravenous S-ketamine (0.57 mg/kg/h) or placebo infusion received oral morphine (0.2 mg/kg) at 30 minutes. Plasma concentrations of ketamine, morphine, and their major metabolites were quantified for 24 hours. The primary end point was area under the curve (AUC) 0-24 of morphine. Other pharmacokinetic variables for morphine and its metabolites were studied as secondary end points. The data were analyzed as between-phase comparisons for each participant using Wilcoxon matched-pairs signed-rank tests ( tmax ) or paired t -tests on log-transformed variables (other variables). RESULTS While the AUC 0-24 was similar between the 2 phases, S-ketamine reduced the AUC 0-1.5 of oral morphine by 69% (ratio to control, 0.31; 90% confidence interval [CI], 0.15-0.65; P = .0171) and increased its tmax from 0.5 (range, 0.50-1.5) to 1.0 hour (range, 0.50-4.0; P = .010). The AUC 0-1.5 of morphine-6-glucuronide (M6G) was reduced by 84% (0.16; 90% CI, 0.07-0.37; P = .0025) and maximum plasma concentration ( Cmax ) by 43% (0.57; 90% CI, 0.40-0.81; P = .0155), while its tmax was increased from 1.5 (range, 1.0-2.0) to 4.0 (range, 1.0-8.0; P = .0094) hours by S-ketamine. Similarly, the AUC 0-1.5 of morphine-3-glucuronide (M3G) was reduced by 85% (0.15; 90% CI, 0.05-0.43; P = .0083), and tmax increased from 1.0 (range, 0.5-1.5) to 4.0 hours (range, 1.0-8.0; P = .0063). In addition, the M6G-to-morphine and M3G-to-morphine metabolic AUC ratios were decreased by 47% (0.53; 90% CI, 0.39-0.71; P = .0033) and 52% (0.48; 90% CI, 0.27-0.85; P = .0043) during 0 to 1.5 hours and by 15% (0.85; 90% CI, 0.78-0.92; P = .0057) and 10% (0.90; 90% CI, 0.83-0.98; P = .0468) during 0 to 24 hours, respectively. One participant was excluded from the analyses due to vomiting in the S-ketamine phase. CONCLUSIONS Intravenous S-ketamine inhibited the metabolism of oral morphine and delayed its absorption, resulting in a net reduction in the exposure to morphine during the first 1.5 hours. Intravenous S-ketamine may delay the absorption and impair the efficacy of orally administered analgesics and other drugs.
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Affiliation(s)
- Terhi J. Lohela
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Satu Poikola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Daniel Backmansson
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Outi Lapatto-Reiniluoto
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- HUS Pharmacy, Helsinki University Hospital, Helsinki, Finland
| | - Janne T. Backman
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Klaus T. Olkkola
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tuomas O. Lilius
- From the Department of Clinical Pharmacology, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Finnish Poison Information Center, Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Mori H, Hashimoto T, Nikai T, Furuya M, Hattori M, Katsube Y, Saito Y. Long-Term Exposure to Morphine Induces Cross-Tolerance to Acute Antinociceptive Effect of Remifentanil on Somatic and Visceral Stimuli in Rats. J Pain Res 2022; 15:4047-4054. [PMID: 36582657 PMCID: PMC9792809 DOI: 10.2147/jpr.s389929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/15/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose Remifentanil is one of the most commonly used opioids intraoperatively. Previous reports indicate that long-term use of opioids may lead to cross-tolerance to remifentanil, which poses a challenge in the control of acute pain intraoperatively. However, there is limited information regarding cross-tolerance to remifentanil, especially in visceral pain. Therefore, this study aimed to examine cross-tolerance to remifentanil in somatic and visceral tolerance using morphine-tolerant rats. Methods Six male Sprague-Dawley rats were allocated to the morphine and saline groups each. Tolerance to the antinociceptive effect of morphine was induced in rats in the morphine group. Remifentanil was continuously infused intravenously at 10 mcg/kg/min for 120 min to assess cross-tolerance from morphine to remifentanil. The antinociceptive effects on somatic and visceral nociceptive stimuli were measured using the tail-flick (TF) and colorectal distension (CD) tests, respectively. The antinociceptive efficacy was evaluated by converting the response threshold to the percentage maximal possible effect (%MPE). Results Remifentanil increased the %MPE in the morphine and saline groups in both the tests; however, the increase in %MPE was attenuated significantly in the morphine group compared with that in the saline group at 60, 90, and 120 min (all P < 0.01) in the TF test and at 90 and 120 min in the CD test (all P <0.05). Conclusion Our results indicate that morphine-tolerant rats exhibit cross-tolerance to remifentanil's acute antinociceptive effects on somatic and visceral stimuli. Cross-tolerance to remifentanil should be considered in the perioperative management of patients using morphine.
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Affiliation(s)
- Hideaki Mori
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Tatsuya Hashimoto
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan,Correspondence: Tatsuya Hashimoto, Department of Anesthesiology, Shimane University Faculty of Medicine, 89-1 Enya-Cho, Izumo, Shimane, 693-8501, Japan, Tel +81-853-20-2295, Fax +81-853-20-2292, Email
| | - Tetsuro Nikai
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Motohide Furuya
- Department of Psychiatry, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Mai Hattori
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yukiko Katsube
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
| | - Yoji Saito
- Department of Anesthesiology, Shimane University Faculty of Medicine, Izumo, Shimane, Japan
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Xu W, Zhao Z, Falconer J, Whittaker AK, Popat A, Smith MT, Kumeria T, Han FY. Sustained release ketamine-loaded porous silicon-PLGA microparticles prepared by an optimized supercritical CO 2 process. Drug Deliv Transl Res 2022; 12:676-694. [PMID: 33907987 DOI: 10.1007/s13346-021-00991-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2021] [Indexed: 12/15/2022]
Abstract
Ketamine in sub-anaesthetic doses has analgesic properties and an opioid-sparing effect. Intrathecal (i.t.) delivery of analgesics bypasses systemic metabolism and delivers the analgesic agent adjacent to the target receptors in the spinal cord and so small doses are required to achieve effective pain relief. In order to relieve intractable cancer-related pain, sustained-release ketamine formulations are required in combination with a strong opioid because frequent i.t. injection is not practical. In this study, ketamine or ketamine-loaded porous silicon (pSi) were encapsulated into poly(lactic-co-glycolic acid) (PLGA) microparticles by a novel supercritical carbon dioxide (scCO2) method, thereby avoiding the use of organic solvent. Multiple parameters including theoretical drug loading (DL), presence of pSi, size of scCO2 vessel, PLGA type, and use of co-solvent were investigated with a view to obtaining high DL and a sustained-release for an extended period. The most important finding was that the use of a large scCO2 vessel (60 mL) resulted in a much higher encapsulation efficiency (EE) compared with a small vessel (12 mL). In addition, pre-loading ketamine into pSi slightly improved the level of drug incorporation (i.e. EE and DL). Although the in vitro release was mainly affected by the drug payload, the use of the large scCO2 vessel reduced the burst release and extended the release period for PLGA microparticles with 10% or 20% ketamine loading. Together, our findings provide valuable information for optimization of drug delivery systems prepared with the aid of scCO2.
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Affiliation(s)
- Weizhi Xu
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Zonglan Zhao
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - James Falconer
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew K Whittaker
- Australia Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia
- ARC Centre of Excellence in Convergent Bio Nano Science and Technology, The University of Queensland, Brisbane, QLD, Australia
| | - Amirali Popat
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
- Translational Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Maree T Smith
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Tushar Kumeria
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia.
- School of Materials Science and Engineering, The University of New South Wales, Sydney, NSW, Australia.
| | - Felicity Y Han
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
- Australia Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia.
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Zhu M, Whittaker AK, Jiang X, Tang R, Li X, Xu W, Fu C, Smith MT, Han FY. Use of Microfluidics to Fabricate Bioerodable Lipid Hybrid Nanoparticles Containing Hydromorphone or Ketamine for the Relief of Intractable Pain. Pharm Res 2020; 37:211. [PMID: 33009588 DOI: 10.1007/s11095-020-02939-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022]
Abstract
PURPOSE For patients with intractable cancer-related pain, administration of strong opioid analgesics and adjuvant agents by the intrathecal (i.t.) route in close proximity to the target receptors/ion channels, may restore pain relief. Hence, the aim of this study was to use bioerodable polymers to encapsulate an opioid analgesic (hydromorphone) and an adjuvant drug (ketamine) to produce prolonged-release formulations for i.t. injection. METHODS A two-stage microfluidic method was used to fabricate nanoparticles (NPs). The physical properties were characterised using dynamic light scattering and transmission electron microscopy. A pilot in vivo study was conducted in a rat model of peripheral neuropathic pain. RESULTS The in vitro release of encapsulated payload from NPs produced with a polymer mixture (CPP-SA/PLGA 50:50) was sustained for 28 days. In a pilot in vivo study, analgesia was maintained over a three day period following i.t. injection of hydromorphone-loaded NPs at 50 μg. Co-administration of ketamine-loaded NPs at 340 μg did not increase the duration of analgesia significantly. CONCLUSIONS The two-stage microfluidic method allowed efficient production of analgesic/adjuvant drug-loaded NPs. Our proof-of-principle in vivo study shows prolonged hydromorphone analgesic for 78 h after single i.t. injection. At the i.t. dose administered, ketamine released from NPs was insufficient to augment hydromorphone analgesia.
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Affiliation(s)
- Minze Zhu
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia.,ARC Centre of Excellence in Convergent Bio Nano Science and Technology, The University of Queensland, Brisbane, QLD, Australia
| | - Xingyu Jiang
- National Center for Nanoscience and Technology, Beijing, China.,Department of Biomedical Engineering, Southern University of Science and Technology, Shenzhen, China
| | - Rupei Tang
- Engineering Research Centre for Biomedical Materials, Anhui University, Hefei, Anhui Province, China
| | - Xuanyu Li
- National Center for Nanoscience and Technology, Beijing, China
| | - Weizhi Xu
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, St Lucia Campus, Brisbane, QLD, 4072, Australia
| | - Changkui Fu
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia.,ARC Centre of Excellence in Convergent Bio Nano Science and Technology, The University of Queensland, Brisbane, QLD, Australia
| | - Maree T Smith
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, St Lucia Campus, Brisbane, QLD, 4072, Australia
| | - Felicity Y Han
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia. .,School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, St Lucia Campus, Brisbane, QLD, 4072, Australia.
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5
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Han FY, Whittaker AK, Howdle SM, Naylor A, Shabir-Ahmed A, Zhang C, Smith MT. Formulation of Bioerodible Ketamine Microparticles as an Analgesic Adjuvant Treatment Produced by Supercritical Fluid Polymer Encapsulation. Pharmaceutics 2018; 10:E264. [PMID: 30563294 PMCID: PMC6321204 DOI: 10.3390/pharmaceutics10040264] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 11/28/2018] [Accepted: 12/04/2018] [Indexed: 01/10/2023] Open
Abstract
Pain is inadequately relieved by escalating doses of a strong opioid analgesic such as morphine in up to 25% of patients with cancer-related severe pain complicated by a neuropathic (nerve damage) component. Hence, there is an unmet medical need for research on novel painkiller strategies. In the present work, we used supercritical fluid polymer encapsulation to develop sustained-release poly(lactic-co-glycolic acid) (PLGA) biodegradable microparticles containing the analgesic adjuvant drug ketamine, for injection by the intrathecal route. Using this approach with a range of PLGA co-polymers, drug loading was in the range 10⁻60%, with encapsulation efficiency (EE) of 60⁻100%. Particles were mainly in the size range 20⁻45 µm and were produced in the absence of organic solvents and surfactants/emulsifiers. Investigation of the ketamine release profiles from these PLGA-based microparticles in vitro showed that release took place over varying periods in the range 0.5⁻4.0 weeks. Of the polymers assessed, the ester end-capped PLGA5050DLG-1.5E gave the best-controlled release profile with drug loading at 10%.
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Affiliation(s)
- Felicity Y Han
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane QLD 4072, Australia.
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane QLD 4072, Australia.
- ARC Centre of Excellence in Convergent Bio Nano Science and Technology, The University of Queensland, Brisbane QLD 4072, Australia.
| | - Steven M Howdle
- School of Chemistry, University of Nottingham, Nottingham NG7 2RD, UK.
- Critical Pharmaceuticals Ltd., BioCity Nottingham, Nottingham NG1 1GF, UK.
| | - Andrew Naylor
- Upperton Limited, Biocity Nottingham, Nottingham NG7 2TN, UK.
| | | | - Cheng Zhang
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane QLD 4072, Australia.
- ARC Centre of Excellence in Convergent Bio Nano Science and Technology, The University of Queensland, Brisbane QLD 4072, Australia.
| | - Maree T Smith
- School of Biomedical Sciences, Faculty of Medicine, The University of Queensland, Brisbane QLD 4072, Australia.
- School of Pharmacy, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane QLD 4072, Australia.
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Lilius TO, Jokinen V, Neuvonen MS, Niemi M, Kalso EA, Rauhala PV. Ketamine coadministration attenuates morphine tolerance and leads to increased brain concentrations of both drugs in the rat. Br J Pharmacol 2016; 172:2799-813. [PMID: 25297798 PMCID: PMC4439876 DOI: 10.1111/bph.12974] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 09/05/2014] [Accepted: 10/03/2014] [Indexed: 12/25/2022] Open
Abstract
Background and Purpose The effects of ketamine in attenuating morphine tolerance have been suggested to result from a pharmacodynamic interaction. We studied whether ketamine might increase brain morphine concentrations in acute coadministration, in morphine tolerance and morphine withdrawal. Experimental Approach Morphine minipumps (6 mg·day–1) induced tolerance during 5 days in Sprague–Dawley rats, after which s.c. ketamine (10 mg·kg–1) was administered. Tail flick, hot plate and rotarod tests were used for behavioural testing. Serum levels and whole tissue brain and liver concentrations of morphine, morphine-3-glucuronide, ketamine and norketamine were measured using HPLC-tandem mass spectrometry. Key Results In morphine-naïve rats, ketamine caused no antinociception whereas in morphine-tolerant rats there was significant antinociception (57% maximum possible effect in the tail flick test 90 min after administration) lasting up to 150 min. In the brain of morphine-tolerant ketamine-treated rats, the morphine, ketamine and norketamine concentrations were 2.1-, 1.4- and 3.4-fold, respectively, compared with the rats treated with morphine or ketamine only. In the liver of morphine-tolerant ketamine-treated rats, ketamine concentration was sixfold compared with morphine-naïve rats. After a 2 day morphine withdrawal period, smaller but parallel concentration changes were observed. In acute coadministration, ketamine increased the brain morphine concentration by 20%, but no increase in ketamine concentrations or increased antinociception was observed. Conclusions and Implications The ability of ketamine to induce antinociception in rats made tolerant to morphine may also be due to increased brain concentrations of morphine, ketamine and norketamine. The relevance of these findings needs to be assessed in humans.
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Affiliation(s)
- T O Lilius
- Institute of Biomedicine, Pharmacology, University of Helsinki, Finland
| | - V Jokinen
- Institute of Biomedicine, Pharmacology, University of Helsinki, Finland
| | - M S Neuvonen
- Haartman Institute, Department of Clinical Pharmacology, University of Helsinki, Finland
| | - M Niemi
- Haartman Institute, Department of Clinical Pharmacology, University of Helsinki, Finland.,HUSLAB, Helsinki University Central Hospital, Finland
| | - E A Kalso
- Institute of Biomedicine, Pharmacology, University of Helsinki, Finland.,Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Medicine, Pain Clinic, Helsinki University Central Hospital, Finland
| | - P V Rauhala
- Institute of Biomedicine, Pharmacology, University of Helsinki, Finland
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Han FY, Thurecht KJ, Lam AL, Whittaker AK, Smith MT. Novel polymeric bioerodable microparticles for prolonged-release intrathecal delivery of analgesic agents for relief of intractable cancer-related pain. J Pharm Sci 2015; 104:2334-44. [PMID: 25990226 DOI: 10.1002/jps.24497] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 04/24/2015] [Accepted: 04/27/2015] [Indexed: 12/19/2022]
Abstract
Intractable cancer-related pain complicated by a neuropathic component due to nerve impingement is poorly alleviated even by escalating doses of a strong opioid analgesic. To address this unmet medical need, we developed sustained-release, bioerodable, hydromorphone (potent strong opioid)- and ketamine (analgesic adjuvant)-loaded microparticles for intrathecal (i.t.) coadministration. Drug-loaded poly(lactic-co-glycolic acid) (PLGA) microparticles were prepared using a water-in-oil-in-water method with evaporation. Encapsulation efficiency of hydromorphone and ketamine in PLGA (50:50) microparticles was 26% and 56%, respectively. Microparticles had the desired size range (20-60 μm) and in vitro release was prolonged at ≥28 days. Microparticles were stable for ≥6 months when stored refrigerated protected from light in a desiccator. Desirably, i.t. injected fluorescent dye-labeled PLGA microparticles in rats remained in the lumbar region for ≥7 days. In a rat model of neuropathic pain, i.t. coinjection of hydromorphone- and ketamine-loaded microparticles (each 1 mg) produced analgesia for 8 h only. Possible explanations include inadequate release of ketamine and/or hydromorphone into the spinal fluid, and/or insufficient ketamine loading to prevent development of analgesic tolerance to the released hydromorphone. As sub-analgesic doses of i.t. ketamine at 24-48 h intervals restored analgesia on each occasion, insufficient ketamine loading appears problematic. We will investigate these issues in future work.
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Affiliation(s)
- Felicity Y Han
- Centre for Integrated Preclinical Drug Development, The University of Queensland, Brisbane, QLD, Australia.,School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia.,Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia
| | - Kristofer J Thurecht
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia.,Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia.,ARC Centre of Excellence in Convergent BioNano Science and Technology, The University of Queensland, Brisbane, QLD, Australia
| | - Ai-Leen Lam
- Centre for Integrated Preclinical Drug Development, The University of Queensland, Brisbane, QLD, Australia
| | - Andrew K Whittaker
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, QLD, Australia.,Centre for Advanced Imaging, The University of Queensland, Brisbane, QLD, Australia.,ARC Centre of Excellence in Convergent BioNano Science and Technology, The University of Queensland, Brisbane, QLD, Australia
| | - Maree T Smith
- Centre for Integrated Preclinical Drug Development, The University of Queensland, Brisbane, QLD, Australia.,School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
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Akhavanakbari G, Mohamadian A, Entezariasl M. Evaluation the effects of adding ketamine to morphine in intravenous patient-controlled analgesia after orthopedic surgery. Perspect Clin Res 2014; 5:85-7. [PMID: 24741486 PMCID: PMC3980550 DOI: 10.4103/2229-3485.128028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Intravenous patient-controlled analgesia (PCA) with morphine is commonly used for post-operative pain after major surgery. Ketamine has analgesic property at lower doses, and in combination with opioids it could have synergistic effect. The aim of this study is to determine effects of the addition of ketamine to morphine for PCA after orthopedic surgery. Materials and Methods: In this double-blind randomized clinical trial, 60 patients were randomly allocated to receive PCA consisting: Group 1 (morphine 0.2 mg/ml), Group 2 (morphine 0.2 mg/ml + ketamine 1 mg/ml), and Group 3 (morphine 0.1 mg/ml + ketamine 2 mg/ml). In this, anesthesiologists managed study, patients had orthopedic surgery. Assessments were made at 24 h and 48 h post-operatively. Visual analog scale (VAS) was used for recording pain score. PCA morphine use was recorded at 24 h and 48 h. VAS scores over 48 h were analyzed with analysis of variance for repeated measures. Significance level was taken as 0.05. Results: There is no significant difference between demographic information of the three groups (P > 0.05). Control of pain in Group 2 and Group 3 was better than in Group 1 (only morphine) (P = 0.001) but there was no significant difference between Group 2 and Group 3 (P > 0.05). Rate of narcotic consumption in groups 2 and 3 was significantly lower than Group 1 (P < 0.05). Conclusion: After orthopedic surgery, the addition of ketamine to morphine for intravenous PCA was superior to Intravenous PCA opioid alone. The combination induces a significant reduction in pain score and cumulative morphine consumption.
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Affiliation(s)
| | - Ali Mohamadian
- Department of Anesthesiology, Ardabil University of Medical Sciences, Iran
| | - Masood Entezariasl
- Department of Anesthesiology, Ardabil University of Medical Sciences, Iran
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9
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Evaluation of the analgesic effect of ketamine as an additive to intrathecal bupivacaine in patients undergoing cesarean section. ACTA ACUST UNITED AC 2014; 51:155-60. [PMID: 24529671 DOI: 10.1016/j.aat.2013.12.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 09/30/2013] [Accepted: 10/03/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Nowadays, conventional analgesic agents, which are widely used for pain relief after cesarean section, provide suboptimal analgesia with occasional serious side effects. We designed a randomized, double-blind, placebo-controlled study to evaluate the analgesic efficacy of intrathecal ketamine added to bupivacaine after cesarean section. METHODS Sixty patients scheduled for cesarean section under spinal anesthesia were randomly allocated to one of the two groups to receive either bupivacaine 10 mg combined with 0.1 mg/kg ketamine, or bupivacaine 10 mg combined with 0.5 mL distilled water intrathecally. The time to the first analgesic request, analgesic requirement in the first 24 hours after surgery, onset times of sensory and motor blockades, the durations of sensory and motor blockades, and the incidences of adverse effects such as hypotension, ephedrine requirement, bradycardia, and hypoxemia, were recorded. RESULTS Patients who received ketamine had a significantly prolonged duration of anesthesia compared with those who did not in the control group [95% confidence intervals (CI) 195-217; p = 0.001]. The mean time to the first analgesic request was also significantly longer in ketamine group (95% CI 252.5-275; p < 0.001). The total analgesic consumption in the 24 hours following surgery significantly lessened in the ketamine group compared with that of the control group (95% CI 2-2.5; p < 0.001). The two groups did not differ significantly in intraoperative and postoperative side effects. CONCLUSION Intrathecal ketamine 0.1 mg/kg co-administered with spinal bupivacaine elongated the time to the first analgesic request and lessened the total analgesic consumption in the first 24 postoperative hours in comparison with bupivacaine alone in the control group following elective cesarean delivery.
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10
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Intrathecal antinociceptive interaction between the NMDA antagonist ketamine and the opioids, morphine and biphalin. Eur J Pain 2012; 12:611-6. [DOI: 10.1016/j.ejpain.2007.10.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Revised: 09/30/2007] [Accepted: 10/14/2007] [Indexed: 11/21/2022]
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12
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Gupta LK, Gupta R, Tripathi CD. N-Methyl-d-aspartate receptor modulators block hyperalgesia induced by acute low-dose morphine. Clin Exp Pharmacol Physiol 2011; 38:592-7. [DOI: 10.1111/j.1440-1681.2011.05556.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Sato C, Okabe T, Nakanishi K, Sakamoto A. A Case of Cancer Pain Management by Long-Term Intrathecal PCA. J NIPPON MED SCH 2010; 77:333-7. [DOI: 10.1272/jnms.77.333] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Chiyo Sato
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School
| | - Tadashi Okabe
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School
| | - Kazuhiro Nakanishi
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School
| | - Atsuhiro Sakamoto
- Department of Anesthesiology and Pain Medicine, Graduate School of Medicine, Nippon Medical School
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14
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Sveticic G, Farzanegan F, Zmoos P, Zmoos S, Eichenberger U, Curatolo M. Is the Combination of Morphine with Ketamine Better than Morphine Alone for Postoperative Intravenous Patient-Controlled Analgesia? Anesth Analg 2008; 106:287-93, table of contents. [DOI: 10.1213/01.ane.0000289637.11065.8f] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Kang K, Shin CH, Lee YH, Cho YW, Park SE, Son HW, Cho SD, Park SH. Effect of Intraarticular Ketamine after Knee Arthroscopy. Korean J Pain 2005. [DOI: 10.3344/kjp.2005.18.2.198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Keon Kang
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Chul Ho Shin
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Young Hee Lee
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Young Woo Cho
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Soon Eun Park
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Hee Won Son
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Sung Do Cho
- Department of Orthopedics, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
| | - Se Hun Park
- Department of Anesthesiology and Pain Management, Ulsan University Hospital, Collage of Medicine, Ulsan University, Ulsan, Korea
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16
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Hassenbusch SJ, Portenoy RK, Cousins M, Buchser E, Deer TR, Du Pen SL, Eisenach J, Follett KA, Hildebrand KR, Krames ES, Levy RM, Palmer PP, Rathmell JP, Rauck RL, Staats PS, Stearns L, Willis KD. Polyanalgesic Consensus Conference 2003: an update on the management of pain by intraspinal drug delivery-- report of an expert panel. J Pain Symptom Manage 2004; 27:540-63. [PMID: 15165652 DOI: 10.1016/j.jpainsymman.2004.03.001] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/03/2004] [Indexed: 11/19/2022]
Abstract
Intraspinal drug infusion using fully implantable pump and catheter systems is a safe and effective therapy for selected patients with chronic pain. The options for this approach are increasing, as drugs that are commercially available for systemic administration are adapted to this use and other drugs that are in development specifically for intraspinal administration become available. In 2000 a Polyanalgesic Consensus Conference was organized to evaluate the existing literature and develop guidelines for drug selection. The major outcome of this effort, an algorithm for drug selection, was based on the best available evidence at the time. Rapid changes have occurred in the science and practice of intraspinal infusion and a Polyanalgesic Consensus Conference 2003 was organized to pursue the following goals: 1) to review the literature on intraspinal drug infusion since 1999, 2) to revise the 2000 drug-selection algorithm, 3) to develop guidelines for optimizing drug dosage and concentration, 4) to create a process for documenting minimum evidence supporting the use of a drug for intraspinal infusion, and 5) to clarify issues pertaining to compounding of drugs. Based on the best available evidence and expert opinion, consensus recommendations were developed in all these areas. The panel's conclusions may provide a foundation for clinical practice and a rational basis for new research.
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Affiliation(s)
- Samuel J Hassenbusch
- Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, 77030, USA
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17
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Vranken JH, van der Vegt MH, Kal JE, Kruis MR. Treatment of neuropathic cancer pain with continuous intrathecal administration of S +-ketamine. Acta Anaesthesiol Scand 2004; 48:249-52. [PMID: 14995949 DOI: 10.1111/j.0001-5172.2004.00284.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The effective treatment of patients suffering from neuropathic cancer pain remains a clinical challenge. When patients experience either insufficient analgesia or problematic side-effects after opioid administration, intrathecal administration of morphine and other medications such as bupivacaine and clonidine may offer significant advantages. Additionally, ketamine, a non-competitive N-methyl-D-Aspartate-receptor antagonist is able to alter pain perception at the spinal level. Because of the potential neurotoxicity after neuraxial use of racemic ketamine, intrathecal administration of the preservative-free active compound, S (+)-ketamine may be a valuable alternative. In this paper, we present a patient with severe neuropathic cancer pain successfully treated by continuous intrathecal infusion of morphine, bupivacaine, clonidine and S (+)-ketamine. Moreover, quality of life measurements before and 3 weeks after the start of spinal treatment revealed an improvement in pain relief and a higher overall quality of life. No clinical signs of neurologic deficit were observed during spinal treatment with S (+)-ketamine. However, the continuous intrathecal administration of S (+)-ketamine should be considered as the last resort because there are no preclinical safety data with relevant concentrations on intrathecal use of S (+)-ketamine.
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Affiliation(s)
- J H Vranken
- Department of Anesthesiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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18
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Rauck RL, Cherry D, Boyer MF, Kosek P, Dunn J, Alo K. Long-term intrathecal opioid therapy with a patient-activated, implanted delivery system for the treatment of refractory cancer pain. THE JOURNAL OF PAIN 2003; 4:441-7. [PMID: 14622664 DOI: 10.1067/s1526-5900(03)00730-2] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The present study evaluated the safety and efficacy of patient-activated delivery of intrathecal morphine sulfate boluses delivered by way of a novel internalized intrathecal delivery system. Patients with refractory cancer pain or uncontrollable side effects were enrolled at 17 US and international sites in this prospective, open-label study. Pain relief, reduction in systemic opioid use, and reduction in opioid-related complications were analyzed both individually and together as a measure of overall success. One hundred forty-nine patients were enrolled and 119 were implanted. Average numeric analog scale pain decreased from 6.1 to 4.2 at 1 month and was maintained through month 7 (P <.01) and through month 13 (P <.05). Systemic opioid use was significantly decreased throughout the study (P <.01). Significant reduction in the opioid complication severity index was demonstrated at all 4 follow-up visits (P <.01). Overall success (>/=50% reduction in numeric analog scale pain, use of systemic opioids, or opioid complication severity index) was reported in 83%, 90%, 85%, and 91% of patients at months 1, 2, 3, and 4, respectively. This study demonstrated that patients with refractory cancer pain or intolerable side effects achieved better analgesia when managed with patient-activated intrathecal delivery of morphine sulfate via an implanted delivery system.
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Affiliation(s)
- Richard L Rauck
- Piedmont Anesthesia and Pain Consultants, PA, Winston-Salem, NC, USA.
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19
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Luginbühl M, Gerber A, Schnider TW, Petersen-Felix S, Arendt-Nielsen L, Curatolo M. Modulation of remifentanil-induced analgesia, hyperalgesia, and tolerance by small-dose ketamine in humans. Anesth Analg 2003; 96:726-732. [PMID: 12598253 DOI: 10.1213/01.ane.0000048086.58161.18] [Citation(s) in RCA: 103] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Adding a small dose of ketamine to opioids may increase the analgesic effect and prevent opioid-induced hyperalgesia and acute tolerance to opioids. In this randomized, double-blinded, placebo-controlled crossover study, we investigated the effect of remifentanil combined with small concentrations of ketamine on different experimental pain models. Pain detection thresholds to single and repeated IM electrical stimulation and to repeated transcutaneous electrical stimulation, pressure pain tolerance threshold, and sedative, respiratory, and cardiovascular side effects were assessed in 14 healthy volunteers. Saline, remifentanil alone, and remifentanil combined with ketamine at target plasma concentrations of 50 or 100 ng/mL were administered in four study sessions. The ketamine infusion was started after baseline testing at a constant target concentration. Remifentanil was started after testing with ketamine alone at an initial target concentration of 1 ng/mL and then increased to 2 ng/mL and decreased to 1 ng/mL. The last test series were started 10 min after discontinuation of remifentanil. Acute remifentanil-induced hyperalgesia and tolerance were detected only by the pressure pain test and were not suppressed by ketamine. Remifentanil alone induced significant analgesia with all pain tests. Ketamine further increased the remifentanil effect only on IM electrical pain. Remifentanil at a 2 ng/mL target concentration induced a slight respiratory depression that was antagonized by ketamine. We conclude that ketamine effects on opioid analgesia are pain-modality specific. IMPLICATIONS Coadministration of ketamine and morphine for pain relief is still controversial. Our experimental pain study with volunteers showed that ketamine enhances opioid analgesia without increasing sedation and reduces respiratory depression. Opioid-induced hyperalgesia and tolerance were not affected by ketamine and depended on the type of nociceptive stimulus. This may explain the conflicting results on opioid tolerance in previous studies.
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Affiliation(s)
- Martin Luginbühl
- *Department of Anesthesiology and §Division of Pain Therapy, University Hospital of Bern, Switzerland; †Department of Anesthesia and Intensive Care, Kantonsspital St. Gallen, Switzerland; and ‡Center for Sensory-Motor Interaction, University of Aalborg, Aalborg, Denmark
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20
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Walker SM, Goudas LC, Cousins MJ, Carr DB. Combination Spinal Analgesic Chemotherapy: A Systematic Review. Anesth Analg 2002. [DOI: 10.1213/00000539-200209000-00033] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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21
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Walker SM, Goudas LC, Cousins MJ, Carr DB. Combination spinal analgesic chemotherapy: a systematic review. Anesth Analg 2002; 95:674-715. [PMID: 12198058 DOI: 10.1097/00000539-200209000-00033] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Suellen M Walker
- Department of Anesthesia and Pain Management, Royal North Shore Hospital and University of Sydney, Sydney, Australia
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22
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Abstract
Control of malignant pain and related symptoms is paramount to clinical success in caring for cancer patients. To achieve the best quality of life for patients and families, oncologists and palliative care clinicians must work together to understand problems related to psychologic, social, and spiritual pain. Pain is the primary problem targeted for control using the World Health Organization's (WHO) analgesic ladder. This article focuses on increased knowledge of analgesic action that may enable expansion of the WHO analgesic ladder to fulfill the broader objectives of palliative medicine. We discuss clinical experience with several classes of drugs that are currently used to treat cancer pain: 1) nonsteroidal anti-inflammatory drugs, with emphasis on cyclooxygenase-2 inhibitors; 2) opioid analgesics, with specific emphasis on methadone and its newly recognized value in cancer pain; 3) ketamine, an antagonist at N-methyl-d-aspartate receptors; and 4) bisphosphonates, used for pain resulting from bone metastases. New concepts that compare molecular actions of morphine at excitatory opioid receptors, and methadone at nonopioid receptor systems, are presented to underscore the importance of balancing central nervous system excitatory (anti-analgesic) versus inhibitory (analgesic) influences.
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Affiliation(s)
- F J McDonnell
- Palliative Care Service, Department of Anesthesiology, University of Kentucky College of Medicine, Rose Street, Lexington, KY 40536, USA.
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23
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Kissin I, Bright CA, Bradley EL. The effect of ketamine on opioid-induced acute tolerance: can it explain reduction of opioid consumption with ketamine-opioid analgesic combinations? Anesth Analg 2000; 91:1483-8. [PMID: 11094005 DOI: 10.1097/00000539-200012000-00035] [Citation(s) in RCA: 119] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
UNLABELLED Ketamine administered intraoperatively in very small doses reduces postoperative opioid consumption. We suggest that this effect is the result of attenuation of acute tolerance to the analgesic effect of opioids. We sought to demonstrate that acute tolerance induced by alfentanil infusion can be attenuated by a dose of ketamine that is too small to produce a direct antinociceptive effect. The experiments were conducted in rats with the use of an infusion algorithm designed to maintain a constant plasma level of the opioid for 4 h. The degree of acute tolerance was determined on the basis of decline in the level of analgesia measured with a tail compression test. Ketamine (10 mg/kg) did not change the baseline pain threshold and did not increase the peak of alfentanil-induced analgesia. At the same time, it attenuated the development of acute tolerance to analgesia during alfentanil infusion and suppressed rebound hyperalgesia observed the day after the infusion. These effects were similar to those observed with dizocilpine (0.1 mg/kg). The development of acute tolerance to analgesia induced by the infusion of an opioid can be attenuated by ketamine administered in doses that are not large enough to provide a direct antinociceptive effect. Therefore, ketamine has the potential to reduce opioid consumption even in subanalgesic doses. IMPLICATIONS Ketamine attenuated the development of acute tolerance to analgesia during alfentanil infusion and suppressed rebound hyperalgesia observed the day after the infusion.
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Affiliation(s)
- I Kissin
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
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24
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Abstract
Control of malignant pain and related symptoms is paramount to clinical success in caring for cancer patients. To achieve the best quality of life for patients and families, oncologists and palliative care clinicians must work together to understand problems related to psychologic, social, and spiritual pain. Pain is the primary problem targeted for control using the World Health Organization's (WHO) analgesic ladder. This article focuses on increased knowledge of analgesic action that may enable expansion of the WHO analgesic ladder to fulfill the broader objectives of palliative medicine. We discuss clinical experience with several classes of drugs that are currently used to treat cancer pain: 1) nonsteroidal anti-inflammatory drugs (NSAIDs), with emphasis on cyclooxygenase-2 (COX-2) inhibitors; 2) opioid analgesics, with specific emphasis on methadone and its newly recognized value in cancer pain; 3) ketamine, an antagonist at N-methyl d-aspartate (NMDA) receptors; and 4) bisphosphonates, used for pain resulting from bone metastases. New concepts that compare molecular actions of morphine at excitatory opioid receptors, and methadone at non-opioid receptor systems, are presented to underscore the importance of balancing central nervous system excitatory (anti-analgesic) versus inhibitory (analgesic) influences.
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Affiliation(s)
- F J McDonnell
- Palliative Care Service, Department of Anesthesiology, University of Kentucky College of Medicine, Rose Street, Lexington, KY 40536, USA.
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