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Mion G, Himmelseher S. Esketamine: Less Drowsiness, More Analgesia. Anesth Analg 2024; 139:78-91. [PMID: 38295061 DOI: 10.1213/ane.0000000000006851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Racemic ketamine is a 1:1 mixture of 2 enantiomers that turn light in opposite direction: Dextrorotatory esketamine is approximately 4 times more affine for the N-methyl-D-aspartate (NMDA) receptor than levorotatory arketamine, which may explain why esketamine is about twice as potent as an analgesic and anesthetic as the racemate. Esketamine has attracted renewed interest in view of the opioid crisis, racemic ketamine's abuse, and esketamine's approval for expanded use. We evaluated the anesthesia literature concerning mental, cardiovascular, cerebral, and antinociceptive effects of esketamine published in English between 1980 and 2022. The review shows that esketamine and racemic ketamine are not "the same" at clinically equivalent analgesic and anesthetic dose: Psychomimetic effects seem to be essentially related to NMDA receptor blockade and esketamine is not devoid of unwanted mental impact. However, it probably involves less cholinergic inhibition. Cognitive disturbances during arousal, awakening, and recovery from the drug are less, and less pronounced with esketamine. The drug allows for an approximately 50% dose reduction in anesthesia and analgesia which goes along with a higher clearance and shorter recovery time as compared to racemic ketamine. In comparison of esketamine with placebo, esketamine shows cardiocirculatory stabilizing and neuroprotective effects which can be seen in anesthesia induction, cardiac surgery, and analgesia and sedation in brain injury. Evidence of esketamine's antinociceptive efficacy is inconsistent, although a recent meta-analysis reports improved pain relief after surgery in a study with short observation time. To better define esketamine's place, direct head-to-head comparison with the racemate at equi-analgesic/anesthetic dose is warranted.
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Affiliation(s)
- Georges Mion
- From the Department of Anesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre, Université Paris - Cité, Cochin Hospital, Paris, France
| | - Sabine Himmelseher
- Department of Anesthesiology and Intensive Care Medicine, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
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2
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Lii TR, Singh V. Ketamine for Complex Regional Pain Syndrome: A Narrative Review Highlighting Dosing Practices and Treatment Response. Anesthesiol Clin 2023; 41:357-369. [PMID: 37245947 PMCID: PMC10688501 DOI: 10.1016/j.anclin.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
This is a narrative review of intravenous ketamine infusions for the treatment of complex regional pain syndrome (CRPS). It briefly covers the definition of CRPS, its epidemiology, and other treatments before introducing ketamine as the article's focus. A summary of ketamine's evidence base and its mechanisms of action is provided. The authors then review ketamine dosages reported in peer-reviewed literature for the treatment of CRPS, and their associated duration of pain relief. The observed response rates to ketamine and predictors of treatment response are also discussed.
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Affiliation(s)
- Theresa R Lii
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, 450 Broadway Street, MC6343, Redwood City, CA 94063, USA
| | - Vinita Singh
- Department of Anesthesiology, Emory University, 550 Peachtree Street, Emory University Hospital Midtown, Atlanta, GA 30308, USA.
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3
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Johnston JN, Henter ID, Zarate CA. The antidepressant actions of ketamine and its enantiomers. Pharmacol Ther 2023; 246:108431. [PMID: 37146727 PMCID: PMC10213151 DOI: 10.1016/j.pharmthera.2023.108431] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/24/2023] [Accepted: 05/02/2023] [Indexed: 05/07/2023]
Abstract
Ketamine, an N-methyl-d-aspartate receptor (NMDAR) antagonist first developed as an anesthetic, has shown significant promise as a medication with rapid antidepressant properties in treatment-resistant depression. However, concerns such as adverse side effects and potential misuse liability have limited its widespread use. Racemic ketamine has two enantiomers-(S)- and (R)-ketamine-that appear to have disparate underlying mechanisms. This brief review summarizes some of the most recent preclinical and clinical research regarding the convergent and divergent prophylactic, immediate, and sustained antidepressant effects of (S)- and (R)-ketamine while addressing potential differences in their side effect and misuse liability profiles. Preclinical research suggests divergent mechanisms underlying (S)- and (R)-ketamine, with (S)-ketamine more directly affecting mechanistic target of rapamycin complex 1 (mTORC1) signaling and (R)-ketamine more directly affecting extracellular signal-related kinase (ERK) signaling. Clinical research suggests that (R)-ketamine has a milder side effect profile than (S)-ketamine and decreases depression rating scale scores, but recent randomized, controlled trials found that it had no significant antidepressant efficacy compared to placebo, suggesting that caution is warranted in interpreting its therapeutic potential. Future preclinical and clinical research is needed to maximize the efficacy of each enantiomer, either by optimizing dose, route of administration, or administration paradigm.
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Affiliation(s)
- Jenessa N Johnston
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MA, United States.
| | - Ioline D Henter
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MA, United States
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MA, United States
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4
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S-ketamine: Is it a ride worth taking? Adverse effects associated with S-ketamine use as an adjuvant or single agent drug. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
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5
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Arpacı AH, Özkoçer SE, Güneş E, Elmas Ç, Işık B. Effects of recurrent ketamine exposure on brain histopathology in juvenile rats. Turk J Med Sci 2023; 53:19-28. [PMID: 36945933 PMCID: PMC10388022 DOI: 10.55730/1300-0144.5554] [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: 05/26/2022] [Accepted: 09/12/2022] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Ketamine (KET) is a commonly used anesthetic agent. However, several previous studies reported that KET leads to neuronal damage in neurodevelopmental stages and has neuroprotective effects. The present experimental study aimed to determine the undesirable histopathological effects of KET in the cerebral cortex, striatum, and hippocampus after recurrent KET administration in juvenile rats. METHODS After ethical approval was obtained, 32 juvenile male Wistar Albino rats were randomized into four groups: 1 mg/kg serum saline intraperitoneally (i.p.), 5 mg/kg KET i.p., 20 mg/kg KET i.p., and 50 mg/kg KET i.p. KET was administered for three consecutive days at three-h intervals in three doses. Ten days after the last KET dose, the rats were sacrificed. Cerebral hemispheres were fixed. Hematoxylin and eosin stain was used for morphometric analysis. Hippocampi were evaluated by immunohistochemistry with anticleaved caspase-3 antibodies. Statistical analysis was conducted with SPSS 21 software using the ANOVA test and Bonferroni post hoc analysis method. RESULTS The experimental study findings revealed no difference between the groups' cell counts or sizes in cortical morphometry. No degenerative changes were observed in pyramidal and granular cells in the striatum. Mild gliosis was observed in the 20 mg/kg and 50 mg/kg KET administration groups. Immuno-histo-chemical analysis was conducted to determine apoptosis in the CA1 region of the hippocampus and revealed that caspase-3 positivity increased with the KET dose. However, there was no statistical difference between the groups. While it was lower than the control group in the 5 mg/kg KET group, it was similar to the control group in the 20 mg/kg KET group and higher in the 50 mg/kg KET group (p > 0.05). DISCUSSION : Repetitive KET exposure did not significantly affect juvenile cerebral morphology and apoptosis in hippocampal cells.
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Affiliation(s)
- Ayşe Hande Arpacı
- Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Ankara University, Ankara, Turkey
| | - Süheyla Esra Özkoçer
- Department of Histology and Embryology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Emel Güneş
- Department of Physiology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Çiğdem Elmas
- Department of Histology and Embryology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Berrin Işık
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Gazi University, Ankara, Turkey
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6
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Carpenter AM, Rodseth RN, Coetzee E, Roodt F, Bye S. Compatibility and stability of an admixture of multiple anaesthetic drugs for opioid-free anaesthesia. Anaesthesia 2022; 77:1202-1208. [PMID: 36039022 DOI: 10.1111/anae.15846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/26/2022] [Indexed: 11/27/2022]
Abstract
The ability to combine and use drugs in a single infusion device may be useful in resource-limited settings. This study examined the chemical stability of an opioid-sparing mixture of ketamine, lidocaine and magnesium sulphate when combined in a single syringe. High-performance liquid chromatography and atomic absorption spectrophotometry were performed on six syringes containing the three-drug mixture. Since most opioid-sparing techniques typically rely on a 24-hour infusion regime, we tested stability at the initial admixing and 24 hours later. Stability was defined as a measured drug concentration within 10% of expected, with the absence of precipitation or pH alterations. Pharmacokinetic simulations were conducted to further show that the achieved plasma drug concentrations were well within an effective analgesic range. All mixed drug concentration measurements were within the required 10% reference limit. No obvious precipitation or interaction occurred, and pH remained stable. Drug stability was maintained for 24 hours. Pharmacokinetic simulations showed that ketamine and lidocaine were within their minimum analgesic effect concentrations. Our results show that this three-drug mixture is chemically stable for up to 24 hours after mixing, with a pharmacokinetic simulation illustrating safe, clinically useful predicted plasma concentrations when using the described admixture.
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Affiliation(s)
| | - R N Rodseth
- Private Practice, University of Kwa-Zulu Natal, Pietermaritzburg, South Africa
| | - E Coetzee
- Groote Schuur Hospital, Cape Town, South Africa
| | - F Roodt
- George Regional Hospital, George, South Africa
| | - S Bye
- Biochemical and Scientific Consultants cc, Pietermaritzburg, South Africa
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7
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Langmia IM, Just KS, Yamoune S, Müller JP, Stingl JC. Pharmacogenetic and drug interaction aspects on ketamine safety in its use as antidepressant - implications for precision dosing in a global perspective. Br J Clin Pharmacol 2022; 88:5149-5165. [PMID: 35863300 DOI: 10.1111/bcp.15467] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/23/2022] [Accepted: 07/12/2022] [Indexed: 12/01/2022] Open
Abstract
Ketamine and its enantiomer S-ketamine (esketamine) are known to produce rapid-onset antidepressant effects in major depression. Intranasal esketamine has recently come into the market as an antidepressant. Besides experience from short-term use in anesthesia and analgesia, the experience with ketamine as long-term medication is rather low. The use of ketamine and esketamine is limited due to potential neurotoxicity, psychocomimetic side effects, potential abuse and interindividual variability in treatment response including cessation of therapy. Therefore, taking a look at individual patient risks and potential underlying variability in pharmacokinetics may improve safety and dosing of these new antidepressant drugs in clinical practice. Differential drug metabolism due to polymorphic cytochrome P450 (CYP) enzymes and gene-drug interactions are known to influence the efficacy and safety of many drugs. Ketamine and esketamine are metabolized by polymorphic CYP enzymes including CYP2B6, CYP3A4, CYP2C9 and CYP2A6. In antidepressant drug therapy, usually multiple drugs are administered which are substrates of CYP enzymes, increasing the risk for drug-drug interactions (DDIs). We reviewed the potential impact of polymorphic CYP variants and common DDIs in antidepressant drug therapy affecting ketamine pharmacokinetics, and the role for dose optimization. The use of ketamine or intranasal esketamine as antidepressants demands a better understanding of the factors that may impact its metabolism and efficacy in long-term use. In addition to other clinical and environmental confounders, prior information on the pharmacodynamic and pharmacokinetic determinants of response variability to ketamine and esketamine may inform on dose optimization and identification of individuals at risk of adverse drug reactions.
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Affiliation(s)
- Immaculate M Langmia
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Katja S Just
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Sabrina Yamoune
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany.,Federal Institute for Drugs and Medical Devices, BfArM, Bonn, Germany
| | - Julian Peter Müller
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
| | - Julia C Stingl
- Institute of Clinical Pharmacology, University Hospital of RWTH Aachen, Aachen, Germany
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Simons P, Olofsen E, van Velzen M, van Lemmen M, Mooren R, van Dasselaar T, Mohr P, Hammes F, van der Schrier R, Niesters M, Dahan A. S-Ketamine Oral Thin Film—Part 1: Population Pharmacokinetics of S-Ketamine, S-Norketamine and S-Hydroxynorketamine. FRONTIERS IN PAIN RESEARCH 2022; 3:946486. [PMID: 35899184 PMCID: PMC9309697 DOI: 10.3389/fpain.2022.946486] [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: 06/23/2022] [Indexed: 11/20/2022] Open
Abstract
Ketamine is administered predominantly via the intravenous route for the various indications, including anesthesia, pain relief and treatment of depression. Here we report on the pharmacokinetics 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 oral thin films on separate occasions in a randomized crossover design. The oral thin films were placed sublingually (n = 15) or buccally (n = 5) and left to dissolve for 10 min in the mouth during which the subjects were not allowed to swallow. For 6 subsequent hours, pharmacokinetic blood samples were obtained after which 20 mg S-ketamine was infused intravenously and blood sampling continued for another 2-hours. A population pharmacokinetic analysis was performed in NONMEM pharmacokinetic model of S-ketamine and its metabolites S-norketamine and S-hydroxynorketamine; p < 0.01 were considered significant. S-ketamine bioavailability was 26 ± 1% (estimate ± standard error of the estimate) with a 20% lower bioavailability of the 100 mg oral thin film relative to the 50 mg film, although this difference did not reach the level of significance. Due to the large first pass-effect, 80% of S-ketamine was metabolized into S-norketamine leading to high plasma levels of S-norketamine following the oral thin film application with 56% of S-ketamine finally metabolized into S-hydroxynorketamine. No differences in pharmacokinetics were observed for the sublingual and buccal administration routes. The S-ketamine oral thin film is a safe and practical alternative to intravenous S-ketamine administration that results in relatively high plasma levels of S-ketamine and its two metabolites.
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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
| | - René Mooren
- 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
- PainLess Foundation, Leiden, Netherlands
- *Correspondence: Albert Dahan
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9
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Bosch OG, Halm S, Seifritz E. Psychedelics in the treatment of unipolar and bipolar depression. Int J Bipolar Disord 2022; 10:18. [PMID: 35788817 PMCID: PMC9256889 DOI: 10.1186/s40345-022-00265-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
This is a narrative review about the role of classic and two atypical psychedelics in the treatment of unipolar and bipolar depression. Since the 1990s, psychedelics experience a renaissance in biomedical research. The so-called classic psychedelics include lysergic acid diethylamide (LSD), psilocybin, mescaline and ayahuasca. Characteristic effects like alterations in sensory perception, as well as emotion- and self-processing are induced by stimulation of serotonin 2A receptors in cortical areas. The new paradigm of psychedelic-assisted psychotherapy suggests a therapeutic framework in which a safely conducted psychedelic experience is integrated into a continuous psychotherapeutic process. First randomized, controlled trials with psilocybin show promising efficacy, tolerability, and adherence in the treatment of unipolar depression. On the other hand, classic psychedelics seem to be associated with the induction of mania, which is an important issue to consider for the design of research and clinical protocols. So called atypical psychedelics are a heterogeneous group with overlapping subjective effects but different neurobiological mechanisms. Two examples of therapeutic value in psychiatry are 3,4-methylenedioxymethamphetamine (MDMA) and ketamine. Since 2020 the ketamine enantiomer esketamine has been granted international approval for treatment-resistant unipolar depression, and also first evidence exists for the therapeutic efficacy of ketamine in bipolar depression. Whether psychedelics will fulfil current expectations and find their way into broader clinical use will depend on future rigorous clinical trials with larger sample sizes. A well-considered therapeutic and legal framework will be crucial for these substances to create new treatment settings and a potential paradigm shift.
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Affiliation(s)
- Oliver G Bosch
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, PO Box 1931, 8032, Zurich, Switzerland.
| | - Simon Halm
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, PO Box 1931, 8032, Zurich, Switzerland
| | - Erich Seifritz
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric University Hospital Zurich, University of Zurich, Lenggstrasse 31, PO Box 1931, 8032, Zurich, Switzerland
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10
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Berlier J, Carabalona JF, Tête H, Bouffard Y, Le-Goff MC, Cerro V, Abrard S, Subtil F, Rimmelé T. Effects of opioid-free anesthesia on postoperative morphine consumption after bariatric surgery. J Clin Anesth 2022; 81:110906. [PMID: 35716634 DOI: 10.1016/j.jclinane.2022.110906] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 05/27/2022] [Accepted: 06/02/2022] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVES The objective of this study was to determine whether postoperative morphine requirement in obese patients undergoing laparoscopic bariatric surgery was reduced by opioid-free anesthesia (OFA), as compared to an anesthetic strategy using opioids (opioid balanced anesthesia (OBA)) and to investigate the differences that may exist between the use of clonidine and dexmedetomidine in the context of OFA. DESIGN Retrospective cohort study. SETTING Academic medical center in Lyon, France. PATIENTS 257 patients who underwent laparoscopic bariatric surgery between March 2017 and March 2019. 77 patients were included in the OBA group and 180 in the OFA group. The OFA group was subdivided in two: 90 patients received OFA with clonidine (OFAC) and 90 received OFA with dexmedetomidine (OFAD). MEASUREMENTS Proportion of patients who did not receive morphine during the first 24 postoperative hours. MAIN RESULTS During the first 24 postoperative hours, the proportion of patients who did not require morphine was significantly higher in the OFA (87%) than in the OBA (52%) group (OR: 6.31; 95% CI [3.38; 11.80], P < 0.001). This difference remained significant after adjustment for age, body mass index, sex, type and duration of surgery (OR: 7.99; 95% CI [4.05; 16.48], P < 0.001). A greater proportion of patients in the OFAD (93%) than in the OFAC group (81%, P = 0.026) did not receive morphine during the same period. CONCLUSIONS OFA is associated with a lower morphine requirement than with OBA during the first 24 h after bariatric surgery. In addition, OFAD seems to be more effective than OFAC in order to reduce morphine consumption.
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Affiliation(s)
- Jean Berlier
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France.
| | - Jean-François Carabalona
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Hugo Tête
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Yves Bouffard
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Mary-Charlotte Le-Goff
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Valérie Cerro
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Stanislas Abrard
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France
| | - Fabien Subtil
- Hospices Civils de Lyon, Lyon, Service de Biostatistique, Lyon, France; Université Claude Bernard Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR, 5558, Villeurbanne, France
| | - Thomas Rimmelé
- Département d'Anesthésie-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Bron, France; EA 7426 Pathophysiology of Injury-Induced Immunosuppression, Université Claude Bernard Lyon 1-Biomérieux-Hospices Civils de Lyon, Lyon, France
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11
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Meshkat S, Rodrigues NB, Di Vincenzo JD, Ceban F, Jaberi S, McIntyre RS, Lui LMW, Rosenblat JD. Pharmacogenomics of ketamine: A systematic review. J Psychiatr Res 2021; 145:27-34. [PMID: 34844049 DOI: 10.1016/j.jpsychires.2021.11.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/18/2021] [Accepted: 11/21/2021] [Indexed: 12/21/2022]
Abstract
Ketamine is a dissociative anesthetic used worldwide for anesthesia, pain management, treatment resistant depression (TRD) and suicidality. Predictors of antidepressant response and adverse effects to ketamine remain poorly understood due to contradictory results. The objective of the systematic review herein is to identify and evaluate the extant literature assessing pharmacogenomic predictors of ketamine clinical benefits and adverse effects. Electronic databases were searched from inception to July 2021 to identify relevant articles. Twelve articles involving 1,219 participants with TRD, 75 who underwent elective surgeries and received ketamine as an anesthetic, 49 with pain, and 68 healthy participants met the inclusion criteria and enrolled to this review. While identified articles reported mixed results, three predictors emerged: 1) Val66Met (rs6265) brain derived neurotrophic factor (BDNF; Met allele) was associated with reduced antidepressant and anti-suicidal effects, 2) CYP2B6*6 (e.g., CYB2B6 metabolizer) was associated with more severe dissociative effects and 3) NET allelic (rs28386840) variant were associated with greater cardiovascular complications (e.g., moderate to severe treatment emergent hypertension). Several important limitations were identified, most notably the small sample sizes and heterogeneity of study design and results. Taken together, preliminary evidence suggests the potential for pharmacogenomic testing to inform clinical practices; however, further research is needed to better determine genetic variants of greatest importance and the clinical validity of pharmacogenomics to help guide ketamine treatment planning.
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Affiliation(s)
- Shakila Meshkat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Joshua D Di Vincenzo
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Felicia Ceban
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Saja Jaberi
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Leanna M W Lui
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada.
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12
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Penning DH, Cazacu S, Brodie A, Jevtovic-Todorovic V, Kalkanis SN, Lewis M, Brodie C. Neuron-Glia Crosstalk Plays a Major Role in the Neurotoxic Effects of Ketamine via Extracellular Vesicles. Front Cell Dev Biol 2021; 9:691648. [PMID: 34604212 PMCID: PMC8481868 DOI: 10.3389/fcell.2021.691648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 08/06/2021] [Indexed: 02/02/2023] Open
Abstract
Background: There is a compelling evidence from animal models that early exposure to clinically relevant general anesthetics (GAs) interferes with brain development, resulting in long-lasting cognitive impairments. Human studies have been inconclusive and are challenging due to numerous confounding factors. Here, we employed primary human neural cells to analyze ketamine neurotoxic effects focusing on the role of glial cells and their activation state. We also explored the roles of astrocyte-derived extracellular vesicles (EVs) and different components of the brain-derived neurotrophic factor (BDNF) pathway. Methods: Ketamine effects on cell death were analyzed using live/dead assay, caspase 3 activity and PARP-1 cleavage. Astrocytic and microglial cell differentiation was determined using RT-PCR, ELISA and phagocytosis assay. The impact of the neuron-glial cell interactions in the neurotoxic effects of ketamine was analyzed using transwell cultures. In addition, the role of isolated and secreted EVs in this cross-talk were studied. The expression and function of different components of the BDNF pathway were analyzed using ELISA, RT-PCR and gene silencing. Results: Ketamine induced neuronal and oligodendrocytic cell apoptosis and promoted pro-inflammatory astrocyte (A1) and microglia (M1) phenotypes. Astrocytes and microglia enhanced the neurotoxic effects of ketamine on neuronal cells, whereas neurons increased oligodendrocyte cell death. Ketamine modulated different components in the BDNF pathway: decreasing BDNF secretion in neurons and astrocytes while increasing the expression of p75 in neurons and that of BDNF-AS and pro-BDNF secretion in both neurons and astrocytes. We demonstrated an important role of EVs secreted by ketamine-treated astrocytes in neuronal cell death and a role for EV-associated BDNF-AS in this effect. Conclusions: Ketamine exerted a neurotoxic effect on neural cells by impacting both neuronal and non-neuronal cells. The BDNF pathway and astrocyte-derived EVs represent important mediators of ketamine effects. These results contribute to a better understanding of ketamine neurotoxic effects in humans and to the development of potential approaches to decrease its neurodevelopmental impact.
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Affiliation(s)
- Donald H Penning
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Simona Cazacu
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, MI, United States.,Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | | | - Vesna Jevtovic-Todorovic
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Steve N Kalkanis
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Michael Lewis
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Hospital, Detroit, MI, United States
| | - Chaya Brodie
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States.,Faculty of Life Sciences, Bar-Ilan University, Ramat Gan, Israel
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Himmelseher S, Kochs EF. Ready for a "breakthrough" with ketamine? A look at recent pharmacological insights! Curr Opin Anaesthesiol 2021; 34:393-401. [PMID: 34052823 DOI: 10.1097/aco.0000000000001017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW To update pharmacological insights on ketamine integrating information from different disciplines for developing steps to "breakthrough" approaches in clinical challenges. RECENT FINDINGS Pharmacokinetic/pharmacodynamic (PK/PD) models have incorporated recirculation, ketamine metabolites, drug-drug interaction, and covariates such as age. Ketamine-induced relief from treatment-resistant depression has been explained by "disinhibition" of gamma-aminobutyric acid-ergic interneurons and synaptogenic mechanisms requiring neurotrophic signals. Neuroimaging/electroencephalographic investigations have shown an increase in gamma spectral power in healthy volunteers and patients with depression, but also opposite changes in functional network connectivity after subanesthetic ketamine. Volunteer data may not be transferable to clinical conditions. Altered states of consciousness induced by subanesthetic ketamine have been described by disruption of resisting-state functional networks and frontoparietal connectivity with preservation of multisensory and sensor-motor networks. This has been interpreted as a "disconnected consciousness". SUMMARY More precise PK/PD models may improve the ketamine use regimen. The findings from research on depression are an important discovery because ketamine's impact on neuronal plasticity and synaptogenesis in human brain disease has directly been documented. Psychic adverse effects with subanesthetic ketamine are related to a "disconnected consciousness". Overall, progress has been made, but the "breakthrough" still has to come.
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Affiliation(s)
- Sabine Himmelseher
- Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
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Weiss M, Siegmund W. Pharmacokinetic Modeling of Ketamine Enantiomers and Their Metabolites After Administration of Prolonged-Release Ketamine With Emphasis on 2,6-Hydroxynorketamines. Clin Pharmacol Drug Dev 2021; 11:194-206. [PMID: 34265182 DOI: 10.1002/cpdd.993] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/30/2021] [Indexed: 01/04/2023]
Abstract
Modeling of metabolite kinetics after oral administration of ketamine is of special interest because of the higher concentrations of active metabolites because of the hepatic first-pass effect. This holds especially in view of the potential analgesic and antidepressant effects of 2R,6R- and 2S,6S-hydroxynorketamine at low doses of ketamine. Therefore, a 9-compartment model was developed to analyze the pharmacokinetics of ketamine enantiomers and their metabolites after racemic ketamine administered intravenously (5 mg) and as 4 doses (10, 20, 40, and 80 mg) of a prolonged-release formulation (PR-ketamine). Using a population approach, the serum concentration-time data of the enantiomers of ketamine, norketamine, dehydronorketamine, and 2,6-hydroxynorketamine obtained in 15 healthy volunteers could be adequately fitted. The estimated model parameters were used to simulate serum concentration-time profiles; after multiple dosing of PR-ketamine (2 daily doses of 20 mg), the steady-state concentrations of R- and S-ketamine were 1.4 and 1.3 ng/mL, respectively. The steady-state concentration of 2R,6R-hydroxynorketamine exceeded those of R-norketamine (4-fold), R-dehydonorketamine (8-fold), and R-ketamine (46-fold), whereas that of 2S,6S-hydroxynorketamine exceeded that of S-ketamine by 14-fold. The model may be useful for identifying dosing regimens aiming at optimal plasma concentrations of 2,6-hydroxynorketamines.
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Affiliation(s)
- Michael Weiss
- Department of Pharmacology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Werner Siegmund
- Department of Clinical Pharmacology, Center of Drug Absorption and Transport (C_DAT), University Medicine Greifswald, Greifswald, Germany
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15
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How relevant is stereoselectivity to the side-effects of ketamine? Br J Anaesth 2021; 127:1-2. [PMID: 33965204 DOI: 10.1016/j.bja.2021.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022] Open
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Chen W, Chen S, Huang Y. Induction and maintenance of procedural sedation in adults: focus on remimazolam injection. Expert Rev Clin Pharmacol 2021; 14:411-426. [PMID: 33686920 DOI: 10.1080/17512433.2021.1901575] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Procedural sedation (PS) is a humane way to help patients get through painful medical procedures by the administration of sedative drugs combined with analgesics. However, each of the currently used medications has certain shortcomings, urging the search for a new drug. Remimazolam, a novel benzodiazepine, is an ultra-short-acting hypnotic agent invented out of the 'soft drug' development.Areas covered: This presented review provides an overview of the drugs used in clinical practice for the induction and maintenance of procedural sedation in adults, focusing on the newly investigated benzodiazepine remimazolam. Literature search was conducted using the MEDLINE and ClinicalTrial.gov databases from January 2007 to December 2020.Expert opinion: Based on the reported clinical trials so far, remimazolam has demonstrated its effectiveness and safety with promising properties including rapid onset, short duration of action, predictable and consistent recovery profile, metabolism almost unaffected by liver or renal function, with non or minimal cardiorespiratory depression, and availability with a reversal drug. With marketing approval received recently, remimazolam is expected to have a place in the practice for procedural sedation in the near future if its efficacy and safety are further confirmed by more clinical trials and post-market analyses.
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Affiliation(s)
- Weiyun Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Shaohui Chen
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
| | - Yuguang Huang
- Department of Anesthesiology, Peking Union Medical College Hospital, Beijing, China
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Otto ME, Bergmann KR, Jacobs G, van Esdonk MJ. Predictive performance of parent-metabolite population pharmacokinetic models of (S)-ketamine in healthy volunteers. Eur J Clin Pharmacol 2021; 77:1181-1192. [PMID: 33575848 PMCID: PMC8275530 DOI: 10.1007/s00228-021-03104-1] [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: 12/18/2020] [Accepted: 02/01/2021] [Indexed: 11/06/2022]
Abstract
Purpose The recent repurposing of ketamine as treatment for pain and depression has increased the need for accurate population pharmacokinetic (PK) models to inform the design of new clinical trials. Therefore, the objectives of this study were to externally validate available PK models on (S)-(nor)ketamine concentrations with in-house data and to improve the best performing model when necessary. Methods Based on predefined criteria, five models were selected from literature. Data of two previously performed clinical trials on (S)-ketamine administration in healthy volunteers were available for validation. The predictive performances of the selected models were compared through visual predictive checks (VPCs) and calculation of the (root) mean (square) prediction errors (ME and RMSE). The available data was used to adapt the best performing model through alterations to the model structure and re-estimation of inter-individual variability (IIV). Results The model developed by Fanta et al. (Eur J Clin Pharmacol 71:441–447, 2015) performed best at predicting the (S)-ketamine concentration over time, but failed to capture the (S)-norketamine Cmax correctly. Other models with similar population demographics and study designs had estimated relatively small distribution volumes of (S)-ketamine and thus overpredicted concentrations after start of infusion, most likely due to the influence of circulatory dynamics and sampling methodology. Model predictions were improved through a reduction in complexity of the (S)-(nor)ketamine model and re-estimation of IIV. Conclusion The modified model resulted in accurate predictions of both (S)-ketamine and (S)-norketamine and thereby provides a solid foundation for future simulation studies of (S)-(nor)ketamine PK in healthy volunteers after (S)-ketamine infusion. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03104-1.
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Affiliation(s)
- M E Otto
- Centre for Human Drug Research, Leiden, The Netherlands.,Leiden Academic Centre for Drug Research, Leiden University, Leiden, The Netherlands
| | - K R Bergmann
- Centre for Human Drug Research, Leiden, The Netherlands
| | - G Jacobs
- Centre for Human Drug Research, Leiden, The Netherlands.,Department of Psychiatry, Leiden University Medical Centre, Leiden, The Netherlands
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Godoy DA, Badenes R, Pelosi P, Robba C. Ketamine in acute phase of severe traumatic brain injury "an old drug for new uses?". CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:19. [PMID: 33407737 PMCID: PMC7788834 DOI: 10.1186/s13054-020-03452-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/22/2020] [Indexed: 01/02/2023]
Abstract
Maintaining an adequate level of sedation and analgesia plays a key role in the management of traumatic brain injury (TBI). To date, it is unclear which drug or combination of drugs is most effective in achieving these goals. Ketamine is an agent with attractive pharmacological and pharmacokinetics characteristics. Current evidence shows that ketamine does not increase and may instead decrease intracranial pressure, and its safety profile makes it a reliable tool in the prehospital environment. In this point of view, we discuss different aspects of the use of ketamine in the acute phase of TBI, with its potential benefits and pitfalls.
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Affiliation(s)
- Daniel Agustin Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.,Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | - Rafael Badenes
- Anesthesiology and Surgical-Trauma Intensive Care, University Clinic Hospital, Valencia, Spain.,Department of Surgery, University of Valencia, Valencia, Spain.,INCLIVA Research Medical Institute, Valencia, Valencia, Spain
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy. .,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
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