1
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Raja SM, Guptill JT, Mack M, Peterson M, Byard S, Twieg R, Jordan L, Rich N, Castledine R, Bourne S, Wilmshurst M, Oxendine S, Avula SGC, Zuleta H, Quigley P, Lawson S, McQuaker SJ, Ahmadkhaniha R, Appelbaum LG, Kowalski K, Barksdale CT, Gufford BT, Awan A, Sancho AR, Moore MC, Berrada K, Cogan GB, DeLaRosa J, Radcliffe J, Pao M, Kennedy M, Lawrence Q, Goldfeder L, Amanfo L, Zanos P, Gilbert JR, Morris PJ, Moaddel R, Gould TD, Zarate CA, Thomas CJ. A Phase 1 Assessment of the Safety, Tolerability, Pharmacokinetics and Pharmacodynamics of (2R,6R)-Hydroxynorketamine in Healthy Volunteers. Clin Pharmacol Ther 2024. [PMID: 39054770 DOI: 10.1002/cpt.3391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
(R,S)-Ketamine (ketamine) is a dissociative anesthetic that also possesses analgesic and antidepressant activity. Undesirable dissociative side effects and misuse potential limit expanded use of ketamine in several mental health disorders despite promising clinical activity and intensifying medical need. (2R,6R)-Hydroxynorketamine (RR-HNK) is a metabolite of ketamine that lacks anesthetic and dissociative activity but maintains antidepressant and analgesic activity in multiple preclinical models. To enable future assessments in selected human indications, we report the safety, tolerability, pharmacokinetics (PK), and pharmacodynamics (PD) of RR-HNK in a Phase 1 study in healthy volunteers (NCT04711005). A six-level single-ascending dose (SAD) (0.1-4 mg/kg) and a two-level multiple ascending dose (MAD) (1 and 2 mg/kg) study was performed using a 40-minute IV administration emulating the common practice for ketamine administration for depression. Safety assessments showed RR-HNK possessed a minimal adverse event profile and no serious adverse events at all doses examined. Evaluations of dissociation and sedation demonstrated that RR-HNK did not possess anesthetic or dissociative characteristics in the doses examined. RR-HNK PK parameters were measured in both the SAD and MAD studies and exhibited dose-proportional increases in exposure. Quantitative electroencephalography (EEG) measurements collected as a PD parameter based on preclinical findings and ketamine's established effect on gamma-power oscillations demonstrated increases of gamma power in some participants at the lower/mid-range doses examined. Cerebrospinal fluid examination confirmed RR-HNK exposure within the central nervous system (CNS). Collectively, these data demonstrate RR-HNK is well tolerated with an acceptable PK profile and promising PD outcomes to support the progression into Phase 2.
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Affiliation(s)
- Shruti M Raja
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeffrey T Guptill
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
- Argenx BV, Ghent, Belgium
| | - Michelle Mack
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Robert Twieg
- Labcorp Bioanalytical Services, Indianapolis, Indiana, USA
| | - Lynn Jordan
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | | | | | - Sarah Oxendine
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Helen Zuleta
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | | | - Reza Ahmadkhaniha
- National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland, USA
| | - Lawrence G Appelbaum
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kevin Kowalski
- Labcorp Bioanalytical Services, Indianapolis, Indiana, USA
| | | | - Brandon T Gufford
- Division of Clinical Pharmacology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Asaad Awan
- Office of the Director, Intramural Research Program, National Institutes of Health, Bethesda, Maryland, USA
| | - Alfredo R Sancho
- Office of the Director, Intramural Research Program, National Institutes of Health, Bethesda, Maryland, USA
| | - Max C Moore
- Drug Discovery and Development Program, Frederick National Laboratory, Fredrick, Maryland, USA
| | - Karim Berrada
- Drug Discovery and Development Program, Frederick National Laboratory, Fredrick, Maryland, USA
| | - Gregory B Cogan
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jesse DeLaRosa
- Duke Early Phase Research Unit, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jeanne Radcliffe
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Maryland Pao
- Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | | | | | - Lisa Goldfeder
- Office of the Director, Intramural Research Program, National Institutes of Health, Bethesda, Maryland, USA
| | - Leslie Amanfo
- Office of the Director, Intramural Research Program, National Institutes of Health, Bethesda, Maryland, USA
| | - Panos Zanos
- Department of Psychology, University of Cyprus, Nicosia, Cyprus
| | - Jessica R Gilbert
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Patrick J Morris
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland, USA
| | - Ruin Moaddel
- National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland, USA
| | - Todd D Gould
- Department of Psychiatry, Pharmacology, and Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Baltimore Veterans Affairs Medical Center, Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA
| | - Craig J Thomas
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland, USA
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
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Das V, Basovich MB, Thomas CJ, Kroin JS, Buvanendran A, McCarthy RJ. A Pharmacological Evaluation of the Analgesic Effect and Hippocampal Protein Modulation of the Ketamine Metabolite (2R,6R)-Hydroxynorketamine in Murine Pain Models. Anesth Analg 2024; 138:1094-1106. [PMID: 37319016 PMCID: PMC10721716 DOI: 10.1213/ane.0000000000006590] [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] [Indexed: 06/17/2023]
Abstract
BACKGROUND The ketamine metabolite (2R,6R)-hydroxynorketamine ([2R,6R]-HNK) has analgesic efficacy in murine models of acute, neuropathic, and chronic pain. The purpose of this study was to evaluate the α-amino-3-hydroxyl-5-methyl-4-isoxazole-propionate (AMPA) dependence of (2R,6R)-HNK analgesia and protein changes in the hippocampus in murine pain models administered (2R,6R)-HNK or saline. METHODS All mice were CD-1 IGS outbred mice. Male and female mice underwent plantar incision (PI) (n = 60), spared nerve injury (SNI) (n = 64), or tibial fracture (TF) (n = 40) surgery on the left hind limb. Mechanical allodynia was assessed using calibrated von Frey filaments. Mice were randomized to receive saline, naloxone, or the brain-penetrating AMPA blocker (1,2,3,4-Tetrahydro-6-nitro-2,3-dioxobenzo [f]quinoxaline-7-sulfonamide [NBQX]) before (2R,6R)-HNK 10 mg/kg, and this was repeated for 3 consecutive days. The area under the paw withdrawal threshold by time curve for days 0 to 3 (AUC 0-3d ) was calculated using trapezoidal integration. The AUC 0-3d was converted to percent antiallodynic effect using the baseline and pretreatment values as 0% and 100%. In separate experiments, a single dose of (2R,6R)-HNK 10 mg/kg or saline was administered to naive mice (n = 20) and 2 doses to PI (n = 40), SNI injury (n = 40), or TF (n = 40) mice. Naive mice were tested for ambulation, rearing, and motor strength. Immunoblot studies of the right hippocampal tissue were performed to evaluate the ratios of glutamate ionotropic receptor (AMPA) type subunit 1 (GluA1), glutamate ionotropic receptor (AMPA) type subunit 2 (GluA2), phosphorylated voltage-gated potassium channel 2.1 (p-Kv2.1), phosphorylated-calcium/calmodulin-dependent protein kinase II (p-CaMKII), brain-derived neurotrophic factor (BDNF), phosphorylated protein kinase B (p-AKT), phosphorylated extracellular signal-regulated kinase (p-ERK), CXC chemokine receptor 4 (CXCR4), phosphorylated eukaryotic translation initiation factor 2 subunit 1 (p-EIF2SI), and phosphorylated eukaryotic translation initiation factor 4E (p-EIF4E) to glyceraldehyde 3-phosphate dehydrogenase (GAPDH). RESULTS No model-specific gender difference in antiallodynic responses before (2R,6R)-HNK administration was observed. The antiallodynic AUC 0-3d of (2R,6R)-HNK was decreased by NBQX but not with pretreatment with naloxone or saline. The adjusted mean (95% confidence interval [CI]) antiallodynic effect of (2R,6R)-HNK in the PI, SNI, and TF models was 40.7% (34.1%-47.3%), 55.1% (48.7%-61.5%), and 54.7% (46.5%-63.0%), greater in the SNI, difference 14.3% (95% CI, 3.1-25.6; P = .007) and TF, difference 13.9% (95% CI, 1.9-26.0; P = .019) compared to the PI model. No effect of (2R,6R)-HNK on ambulation, rearing, or motor coordination was observed. Administration of (2R,6R)-HNK was associated with increased GluA1, GluA2, p-Kv2.1, and p-CaMKII and decreased BDNF ratios in the hippocampus, with model-specific variations in proteins involved in other pain pathways. CONCLUSIONS (2R,6R)-HNK analgesia is AMPA-dependent, and (2R,6R)-HNK affected glutamate, potassium, calcium, and BDNF pathways in the hippocampus. At 10 mg/kg, (2R,6R)-HNK demonstrated a greater antiallodynic effect in models of chronic compared with acute pain. Protein analysis in the hippocampus suggests that AMPA-dependent alterations in BDNF-TrkB and Kv2.1 pathways may be involved in the antiallodynic effect of (2R,6R)-HNK.
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Affiliation(s)
- Vaskar Das
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612
| | - Michael B. Basovich
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612
| | - Craig J. Thomas
- Division of Preclinical Innovation, Chemistry Technologies, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD 20850
| | - Jeffrey S. Kroin
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612
| | | | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, IL 60612
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Hillhouse TM, Partridge KJ, Garrett PI, Honeycutt SC, Porter JH. Effects of (2R,6R)-hydroxynorketamine in assays of acute pain-stimulated and pain-depressed behaviors in mice. PLoS One 2024; 19:e0301848. [PMID: 38640139 PMCID: PMC11029659 DOI: 10.1371/journal.pone.0301848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Accepted: 03/22/2024] [Indexed: 04/21/2024] Open
Abstract
Ketamine has been shown to produce analgesia in various acute and chronic pain states; however, abuse liability concerns have limited its utility. The ketamine metabolite (2R,6R)-hydroxynorketamine (HNK) has been shown to produce antidepressant-like effects similar to ketamine without abuse liability concerns. (2R,6R)-HNK produces sustained analgesia in models of chronic pain, but has yet to be evaluated in models of acute pain. The present study evaluated the efficacy of acute (2R,6R)-HNK administration (one injection) in assays of pain-stimulated (52- and 56-degree hot plate test and acetic acid writhing) and pain-depressed behavior (locomotor activity and rearing) in male and female C57BL/6 mice. In assays of pain-stimulated behaviors, (2R,6R)-HNK (1-32 mg/kg) failed to produce antinociception in the 52- and 56-degree hot plate and acetic acid writhing assays. In assays of pain-depressed behaviors, 0.56% acetic acid produced a robust depression of locomotor activity and rearing that was not blocked by pretreatment of (2R,6R)-HNK (3.2-32 mg/kg). The positive controls morphine (hot plate test) and ketoprofen (acetic acid writhing, locomotor activity, and rearing) blocked pain-stimulated and pain-depressed behaviors. Finally, the effects of intermittent (2R,6R)-HNK administration were evaluated in 52-degree hot plate and pain-depressed locomotor activity and rearing. Intermittent administration of (2R,6R)-HNK also did not produce antinociceptive effects in the hot plate or pain-depressed locomotor activity assays. These results suggest that (2R,6R)-HNK is unlikely to have efficacy in treating acute pain; however, the efficacy of (2R,6R)-HNK in chronic pain states should continue to be evaluated.
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Affiliation(s)
- Todd M. Hillhouse
- Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin, United States of America
| | - Kaitlyn J. Partridge
- Department of Psychology, University of Wisconsin Green Bay, Green Bay, Wisconsin, United States of America
- Department of Cell Biology, Neurobiology, and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Patrick I. Garrett
- Department of Pharmacology and Toxicology, Brody School of Medicine, East Carolina University, Greenville, North Carolina, United States of America
| | - Sarah C. Honeycutt
- Department of Psychology, University at Buffalo, Buffalo, New York, United States of America
| | - Joseph H. Porter
- Department of Psychology, Virginia Commonwealth University, Richmond, Virginia, United States of America
- Department of Psychological Sciences, Northern Michigan, Marquette, Michigan, United States of America
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Peng F, Liu J, Chen J, Wu W, Zhang Y, Zhao G, Kang Y, Gong D, He L, Wang J, Zhang W, Qiu F. Nanocrystals Slow-Releasing Ropivacaine and Doxorubicin to Synergistically Suppress Tumor Recurrence and Relieve Postoperative Pain. ACS NANO 2023; 17:20135-20152. [PMID: 37805931 DOI: 10.1021/acsnano.3c05831] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Although surgical resection provides a straightforward and effective treatment for most malignant solid tumors, tumor recurrence and acute postoperative pain continue to be two big problems associated with this treatment. To resolve these problems, a nanocrystal composite slow-releasing ropivacaine and doxorubicin was fabricated in this study. Briefly, a self-assembling peptide was used to form nanoparticle complexes with the two drugs, based on which homogeneous nanocrystals were obtained by adjusting the pH. In cultured human melanoma cells, the nanocrystals exhibited improved antitumor activity due to a synergistic effect and enhanced cellular uptake of the two drugs. On the other hand, the nanocrystals could slowly release ropivacaine in vitro and in vivo, generating long-acting analgesia on the rat sciatic nerve block model and incisional pain model. On a nude mouse tumor resection model, the nanocrystals simultaneously suppressed the recurrence of solid tumor and relieved postoperative pain, indicating a potential postoperative treatment for tumor resection patients. This nanocrystal system also suggested a promising and facile strategy for developing multifunctional formulations combining different drugs, which could achieve better therapeutic outcomes in a synergistic and sustained manner.
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Affiliation(s)
- Fei Peng
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Junjie Chen
- Department of Burn and Plastic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Weiwei Wu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yujun Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Guoyan Zhao
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yi Kang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Deying Gong
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Liu He
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jing Wang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Wensheng Zhang
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Feng Qiu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
- Laboratory of Anesthesia and Critical Care Medicine, National-Local Joint Engineering Research Center of Translational Medicine of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, China
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Liu AR, Lin ZJ, Wei M, Tang Y, Zhang H, Peng XG, Li Y, Zheng YF, Tan Z, Zhou LJ, Feng X. The potent analgesia of intrathecal 2R, 6R-HNK via TRPA1 inhibition in LF-PENS-induced chronic primary pain model. J Headache Pain 2023; 24:141. [PMID: 37858040 PMCID: PMC10585932 DOI: 10.1186/s10194-023-01667-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/11/2023] [Indexed: 10/21/2023] Open
Abstract
BACKGROUND Chronic primary pain (CPP) is an intractable pain of unknown cause with significant emotional distress and/or dysfunction that is a leading factor of disability globally. The lack of a suitable animal model that mimic CPP in humans has frustrated efforts to curb disease progression. 2R, 6R-hydroxynorketamine (2R, 6R-HNK) is the major antidepressant metabolite of ketamine and also exerts antinociceptive action. However, the analgesic mechanism and whether it is effective for CPP are still unknown. METHODS Based on nociplastic pain is evoked by long-term potentiation (LTP)-inducible high- or low-frequency electrical stimulation (HFS/LFS), we wanted to develop a novel CPP mouse model with mood and cognitive comorbidities by noninvasive low-frequency percutaneous electrical nerve stimulation (LF-PENS). Single/repeated 2R, 6R-HNK or other drug was intraperitoneally (i.p.) or intrathecally (i.t.) injected into naïve or CPP mice to investigate their analgesic effect in CPP model. A variety of behavioral tests were used to detect the changes in pain, mood and memory. Immunofluorescent staining, western blot, reverse transcription-quantitative real-time polymerase chain reaction (RT-qPCR) and calcium imaging of in cultured dorsal root ganglia (DRG) neurons by Fluo-8-AM were used to elucidate the role and mechanisms of 2R, 6R-HNK in vivo or in vitro. RESULTS Intrathecal 2R, 6R-HNK, rather than intraperitoneal 2R, 6R-HNK or intrathecal S-Ketamine, successfully mitigated HFS-induced pain. Importantly, intrathecal 2R, 6R-HNK displayed effective relief of bilateral pain hypersensitivity and depressive and cognitive comorbidities in a dose-dependent manner in LF-PENS-induced CPP model. Mechanically, 2R, 6R-HNK markedly attenuated neuronal hyperexcitability and the upregulation of calcitonin gene-related peptide (CGRP), transient receptor potential ankyrin 1 (TRPA1) or vanilloid-1 (TRPV1), and vesicular glutamate transporter-2 (VGLUT2) in peripheral nociceptive pathway. In addition, 2R, 6R-HNK suppressed calcium responses and CGRP overexpression in cultured DRG neurons elicited by the agonists of TRPA1 or/and TRPV1. Strikingly, the inhibitory effects of 2R, 6R-HNK on these pain-related molecules and mechanical allodynia were substantially occluded by TRPA1 antagonist menthol. CONCLUSIONS In the newly designed CPP model, our findings highlighted the potential utility of intrathecal 2R, 6R-HNK for preventing and therapeutic modality of CPP. TRPA1-mediated uprgulation of CGRP and neuronal hyperexcitability in nociceptive pathways may undertake both unique characteristics and solving process of CPP.
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Affiliation(s)
- An-Ran Liu
- Department of Anesthesiology and Pain Clinic, First Affiliated Hospital of Sun Yat-Sen University, No.58, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Zhen-Jia Lin
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Ming Wei
- Department of Anesthesiology and Pain Clinic, First Affiliated Hospital of Sun Yat-Sen University, No.58, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Yuan Tang
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Hui Zhang
- Department of Anesthesiology, Guangdong Second Provincial General Hospital, No.466, Mid Xingang Road, Haizhu District, Guangzhou, 510317, China
| | - Xiang-Ge Peng
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Ying Li
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Yu-Fan Zheng
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China
| | - Zhi Tan
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China.
| | - Li-Jun Zhou
- Department of Physiology and Pain Research Center, Zhongshan School of Medicine, Guangdong Province Key Laboratory of Brain Function and Disease, Sun Yat-Sen University, No.74, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China.
| | - Xia Feng
- Department of Anesthesiology and Pain Clinic, First Affiliated Hospital of Sun Yat-Sen University, No.58, 2Nd Zhongshan Road, Yuexiu District, Guangzhou, 510080, China.
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Ma X, Yan J, Jiang H. Application of Ketamine in Pain Management and the Underlying Mechanism. Pain Res Manag 2023; 2023:1928969. [PMID: 37622028 PMCID: PMC10447145 DOI: 10.1155/2023/1928969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/26/2023]
Abstract
Since ketamine was approved by the FDA as an intravenous anesthetic, it has been in clinical use for more than 50 years. Apart from its anesthetic effects, ketamine is one of the few intravenous anesthetics with potent analgesic properties. As part of the effort to develop pain management, renewed interest has focused on the use of ketamine for the treatment of acute and chronic pain. Ketamine is commonly used to treat various kinds of chronic pain syndromes and is also applied to control perioperative pain and reduce the consumption of postoperative analgesics. However, its precise mechanisms of action remain mysterious for a large part. Despite extensive research in the field, the mechanism of ketamine is still unclear. Its analgesic effect appears to be largely mediated by blockade of NMDARs, but opioid, GABA, and monoaminergic system seem to partly participate in the pain transmission procedure. Its metabolites also have an analgesic effect, which may prolong pain relief. More recently, the antidepressant effect of ketamine has been considered to reduce pain-related aversion to relieve chronic pain. Overall, the analgesic mechanism of ketamine seems to be a complex combination of multiple factors. Due to its potent analgesic properties, ketamine is an analgesic with great clinical application prospects. Exploring the precise mechanism of action of ketamine will help guide clinical medication and confirm indications for ketamine analgesia. This review aims to list the application of ketamine in pain management and discuss its analgesic mechanism.
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Affiliation(s)
- Xiaofan Ma
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jia Yan
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Riccardi A, Guarino M, Serra S, Spampinato MD, Vanni S, Shiffer D, Voza A, Fabbri A, De Iaco F. Narrative Review: Low-Dose Ketamine for Pain Management. J Clin Med 2023; 12:jcm12093256. [PMID: 37176696 PMCID: PMC10179418 DOI: 10.3390/jcm12093256] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 05/15/2023] Open
Abstract
Pain is the leading cause of medical consultations and occurs in 50-70% of emergency department visits. To date, several drugs have been used to manage pain. The clinical use of ketamine began in the 1960s and it immediately emerged as a manageable and safe drug for sedation and anesthesia. The analgesic properties of this drug were first reported shortly after its use; however, its psychomimetic effects have limited its use in emergency departments. Owing to the misuse and abuse of opioids in some countries worldwide, ketamine has become a versatile tool for sedation and analgesia. In this narrative review, ketamine's role as an analgesic is discussed, with both known and new applications in various contexts (acute, chronic, and neuropathic pain), along with its strengths and weaknesses, especially in terms of psychomimetic, cardiovascular, and hepatic effects. Moreover, new scientific evidence has been reviewed on the use of additional drugs with ketamine, such as magnesium infusion for improving analgesia and clonidine for treating psychomimetic symptoms. Finally, this narrative review was refined by the experience of the Pain Group of the Italian Society of Emergency Medicine (SIMEU) in treating acute and chronic pain with acute manifestations in Italian Emergency Departments.
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Affiliation(s)
| | - Mario Guarino
- Emergency Department, Centro Traumatologico Ortopedico, Azienda Ospedaliera di Rilievo Nazionale dei Colli, 80131 Napoli, Italy
| | - Sossio Serra
- Emergency Department, Maurizio Bufalini Hospital, 47522 Cesena, Italy
| | | | - Simone Vanni
- Dipartimento Emergenza e Area Critica, Azienda USL Toscana Centro Struttura Complessa di Medicina d'Urgenza, 50053 Empoli, Italy
| | - Dana Shiffer
- Emergency Department, Humanitas University, Via Rita Levi Montalcini 4, 20089 Milan, Italy
| | - Antonio Voza
- Emergency Department, IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Andrea Fabbri
- Emergency Department, AUSL Romagna, Presidio Ospedaliero Morgagni-Pierantoni, 47121 Forlì, Italy
| | - Fabio De Iaco
- Emergency Department, Ospedale Maria Vittoria, 10144 Turin, Italy
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Garcia GP, Perez GM, Gasperi RD, Sosa MAG, Otero-Pagan A, Abutarboush R, Kawoos U, Statz JK, Patterson J, Zhu CW, Hof PR, Cook DG, Ahlers ST, Elder GA. (2R,6R)-Hydroxynorketamine Treatment of Rats Exposed to Repetitive Low-Level Blast Injury. Neurotrauma Rep 2023; 4:197-217. [PMID: 37020715 PMCID: PMC10068674 DOI: 10.1089/neur.2022.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Many military veterans who experienced blast-related traumatic brain injuries (TBIs) in the conflicts in Iraq and Afghanistan suffer from chronic cognitive and mental health problems, including post-traumatic stress disorder (PTSD). Male rats subjected to repetitive low-level blast exposure develop chronic cognitive and PTSD-related traits that develop in a delayed manner. Ketamine has received attention as a treatment for refractory depression and PTSD. (2R,6R)-hydroxynorketamine [(2R,6R)-HNK] is a ketamine metabolite that exerts rapid antidepressant actions. (2R,6R)-HNK has become of clinical interest because of its favorable side-effect profile, low abuse potential, and oral route of administration. We treated three cohorts of blast-exposed rats with (2R,6R)-HNK, beginning 7-11 months after blast exposure, a time when the behavioral phenotype is established. Each cohort consisted of groups (n = 10-13/group) as follows: 1) Sham-exposed treated with saline, 2) blast-exposed treated with saline, and 3) blast-exposed treated with a single dose of 20 mg/kg of (2R,6R)-HNK. (2R,6R)-HNK rescued blast-induced deficits in novel object recognition (NOR) and anxiety-related features in the elevated zero maze (EZM) in all three cohorts. Exaggerated acoustic startle was reversed in cohort 1, but not in cohort 3. (2R,6R)-HNK effects were still present in the EZM 12 days after administration in cohort 1 and 27 days after administration in NOR testing of cohorts 2 and 3. (2R,6R)-HNK may be beneficial for the neurobehavioral syndromes that follow blast exposure in military veterans. Additional studies will be needed to determine whether higher doses or more extended treatment regimens may be more effective.
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Affiliation(s)
- Georgina Perez Garcia
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gissel M. Perez
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rita De Gasperi
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Miguel A. Gama Sosa
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- General Medical Research Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Alena Otero-Pagan
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
| | - Rania Abutarboush
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Usmah Kawoos
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Jonathan K. Statz
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland, USA
| | - Jacob Patterson
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Carolyn W. Zhu
- Research and Development Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Patrick R. Hof
- Nash Family Department of Neuroscience and Friedman Brain Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David G. Cook
- Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington, USA
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Stephen T. Ahlers
- Department of Neurotrauma, Naval Medical Research Center, Silver Spring, Maryland, USA
| | - Gregory A. Elder
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Mount Sinai Alzheimer's Disease Research Center and Ronald M. Loeb Center for Alzheimer's Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Neurology Service, James J. Peters Department of Veterans Affairs Medical Center, Bronx, New York, USA
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9
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Ma X, Peng J, Chen Y, Wang Z, Zhou Q, Yan J, Jiang H. Esketamine Anesthetizes Mice With a Similar Potency to Racemic Ketamine. Dose Response 2023; 21:15593258231157563. [PMID: 36798635 PMCID: PMC9926386 DOI: 10.1177/15593258231157563] [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: 11/29/2022] [Accepted: 01/27/2023] [Indexed: 02/13/2023] Open
Abstract
Esketamine, the right-handed optical isomer of racemic ketamine, has recently become widely used for anesthesia and analgesia as a replacement for racemic ketamine. However, there are limited studies comparing the anesthetic and analgesic effects of esketamine and racemic ketamine in mice. This research was conducted to analyze the dose-dependent anesthetic and analgesic efficacy of esketamine in mice and to compare its potency with that of the racemate. We tested the anesthetic effects of different doses of esketamine and compared its potency with that of the racemate using righting reflex tests. Then, the acetic acid-induced pain model and formalin-induced pain model were used to investigate the analgesic effect. Compared with racemic ketamine, an equivalent dose of esketamine at 100 mg/kg was required to induce stable anesthesia. In contrast, 5 mg/kg esketamine was sufficient to provide analgesic effects similar to those of 10 mg/kg ketamine. Together, esketamine had a similar potency to racemic ketamine for anesthesia and a stronger potency for analgesia in mice.
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Affiliation(s)
- Xiaofan Ma
- Department of Anesthesiology, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital, Shanghai, China
| | - Jiali Peng
- Department of Anesthesiology, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital, Shanghai, China
| | - Yelin Chen
- Interdisciplinary Research Center on Biology and Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai, China
| | - Zeyi Wang
- School of Chemical Biology and Biotechnology, Peking University Shenzhen Graduate School, Shenzhen, China
| | - Qiang Zhou
- School of Chemical Biology and Biotechnology, Peking University Shenzhen Graduate School, Shenzhen, China
| | - Jia Yan
- Department of Anesthesiology, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital, Shanghai, China,Jia Yan, Department of Anesthesiology, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital, No. 639, Zhizaoju Road, Shanghai 200011, China.
| | - Hong Jiang
- Department of Anesthesiology, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People’s Hospital, Shanghai, China,Hong Jiang, Department of Anesthesiology, Shanghai Jiao Tong University School of Medicine Affiliated Ninth People's Hospital, No. 639, Zhizaoju Road, Shanghai, China.
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10
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Goswami N, Aleem M, Manda K. Intranasal (2R, 6R)-hydroxynorketamine for acute pain: Behavioural and neurophysiological safety analysis in mice. Clin Exp Pharmacol Physiol 2023; 50:169-177. [PMID: 36371631 DOI: 10.1111/1440-1681.13737] [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: 03/14/2022] [Revised: 10/12/2022] [Accepted: 11/09/2022] [Indexed: 11/14/2022]
Abstract
Ketamine is known for its antinociceptive effect and is also used for treatment-resistant depression. However, the efficacy and safety of (2R, 6R)-hydroxynorketamine (HNK), a ketamine metabolite has been sparingly investigated for acute pain management. The current study aims at investigating the antinociceptive effect of intranasal (2R, 6R)-HNK using pre-clinical models of acute pain. Additionally, the behavioural and neurophysiological safety analyses were carried out for the effective time window. Antinociceptive efficacy of (2R, 6R)-HNK was evaluated using the hot plate test and Hargreaves' plantar test. The formalin test was carried out in both the acute and tonic phases. The neurophysiological and behavioural safety analyses were carried out separately for the haemodynamic function, cortical electroencephalography (EEG), and spontaneous behavioural functions. Analgesic effect of (2R, 6R)-HNK was evident by a significant increase in paw-withdrawal latency in both Hargreaves' and hot plate tests. Additionally, the (2R, 6R)-HNK showed a significant ameliorative effect on pain-related behaviour in the second phase of the formalin test. (2R, 6R)-HNK exhibited an anxiolytic effect without causing any significant changes in locomotor activity and haemodynamic parameters. Power spectral density (PSD) analysis of electroencephalogram revealed no significant changes except a comparative increase in the gamma band range. Both the locomotor functions in the open field test and the PSD value of delta wave indicated no sedative effect at the given dose of (2R, 6R)-HNK. The results demonstrated the pain-alleviating effect of (2R, 6R)-HNK without compromising the neurophysiological and behavioural function. Therefore, intranasal (2R, 6R)-HNK is suggested as a safe candidate for further clinical study in the management of acute pain.
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Affiliation(s)
- Nidhi Goswami
- Division of Behavioral Neuroscience, Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Mohd Aleem
- Division of Behavioral Neuroscience, Institute of Nuclear Medicine & Allied Sciences, Delhi, India
| | - Kailash Manda
- Division of Behavioral Neuroscience, Institute of Nuclear Medicine & Allied Sciences, Delhi, India
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11
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Li Y, Du Y, Wang C, Lu G, Sun H, Kong Y, Wang W, Lian B, Li C, Wang L, Zhang X, Sun L. (2R,6R)-hydroxynorketamine acts through GluA1-induced synaptic plasticity to alleviate PTSD-like effects in rat models. Neurobiol Stress 2022; 21:100503. [PMID: 36532380 PMCID: PMC9755068 DOI: 10.1016/j.ynstr.2022.100503] [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: 08/12/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Post-traumatic stress disorder (PTSD) is a debilitating mental disorder with high morbidity and great social and economic relevance. However, extant pharmacotherapies of PTSD require long-term use to maintain effectiveness and have enormous side effects. The glutamatergic system, especially the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor (AMPAR), is an important target of current research on the mechanism of PTSD. Postsynaptic AMPAR function and expression are known to be increased by (2R, 6R)-hydronorketamine (HNK), the primary metabolite of ketamine. However, whether (2R,6R)-HNK alleviates PTSD-like effects via AMPAR upregulation is yet to be known. In the present study, rats were exposed to single prolonged stress and electric foot shock (SPS&S). Afterwards, gradient concentrations of (2R,6R)-HNK (20, 50, and 100 μM) were administered by intracerebroventricular (i.c.v.) injection. Open field, elevated plus maze, freezing behavior, and forced swimming tests were used to examine PTSD-like symptoms. In addition, the protein levels of GluA1, BDNF and PSD-95 were analyzed using western blotting and immunofluorescence, and the synaptic ultrastructure of the prefrontal cortex (PFC) was observed by transmission electron microscopy. We found that (2R,6R)-HNK changed SPS&S-induced behavioral expression, such as increasing autonomous activity and residence time in the open arm and decreasing immobility time. Likewise, (2R,6R)-HNK (50 μM) increased GluA1, BDNF, and PSD-95 protein expression in the PFC. Changes in synaptic ultrastructure induced by SPS&S were reversed by administration of (2R,6R)-HNK. Overall, we find that (2R,6R)-HNK can ameliorate SPS&S-induced fear avoidance in rats, as well as rat cognates of anxiety and depression. This may be related to GluA1-mediated synaptic plasticity in the PFC.
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Affiliation(s)
- Yu Li
- School of Psychology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - YaLin Du
- School of Clinical Medicine, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - Chen Wang
- School of Psychology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - GuoHua Lu
- School of Psychology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - HongWei Sun
- School of Psychology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - YuJia Kong
- School of Public Health, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - WeiWen Wang
- Institute of Psychology of the Chinese Academy of Sciences, PR China
| | - Bo Lian
- Department of Bioscience and Technology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - ChangJiang Li
- School of Psychology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
| | - Ling Wang
- Weifang Medical University, Clinical Competency Training Center Medical Experiment and Training Center, PR China
| | - XianQiang Zhang
- Peking University Sixth Hospital/Institute of Mental Health and the Key Laboratory of Mental Health, Ministry of Health (Peking University), Beijing, China
| | - Lin Sun
- School of Psychology, Weifang Medical University, 7166# Baotong West Street, Weifang, Shandong, 261053, PR China
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12
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Yost JG, Browne CA, Lucki I. (2R,6R)-hydroxynorketamine (HNK) reverses mechanical hypersensitivity in a model of localized inflammatory pain. Neuropharmacology 2022; 221:109276. [PMID: 36198332 DOI: 10.1016/j.neuropharm.2022.109276] [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: 06/07/2022] [Revised: 09/20/2022] [Accepted: 09/27/2022] [Indexed: 10/07/2022]
Abstract
The ketamine metabolite (2R,6R)-hydroxynorketamine, or (2R,6R)-HNK, was recently reported to evoke antinociception in response to a noxious thermal stimulus in healthy mice and reverse mechanical hypersensitivity in a murine model of neuropathic pain. This study reports the behavioral effects of (2R,6R)-HNK in male and female C57BL/6J mice exposed to a localized inflammatory pain condition and the broad pharmacological mechanism underlying this effect. Hind paw intraplantar injection of λ-carrageenan (CARR) caused inflammation and mechanical hypersensitivity in mice within 2 hours, lasting at least 48 hours. Intraperitoneal administration of (2R,6R)-HNK (10-30 mg/kg i.p.) 2 hours following CARR injection significantly reversed mechanical hypersensitivity within 1 hour in male and female mice, and the effect persisted for 24 hours following a single dose. The magnitude and timing of the analgesic effect of (2R,6R)-HNK were comparable to the non-steroidal anti-inflammatory drug carprofen. The reversal of hypersensitivity by (2R,6R)-HNK was blocked at 4 and 24 hours after administration by pretreatment with the AMPA receptor antagonist NBQX and was not accompanied by changes in locomotor activity. These findings reinforce the growing evidence supporting (2R,6R)-HNK as a novel analgesic in multiple preclinical pain models and further support an AMPAR-dependent mechanism of action. SIGNIFICANCE: The ketamine metabolite (2R,6R)-HNK reversed mechanical hypersensitivity associated with localized inflammation with onset less than one hour and duration greater than 24 hours in an effect comparable to the NSAID carprofen. Reversal of mechanical hypersensitivity by (2R,6R)-HNK is AMPAR-dependent.
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Affiliation(s)
- Jonathan G Yost
- Neuroscience Graduate Program, Uniformed Services University, Bethesda, MD, 20814, USA
| | - Caroline A Browne
- Neuroscience Graduate Program, Uniformed Services University, Bethesda, MD, 20814, USA; Department of Pharmacology and Molecular Therapeutics, Uniformed Services University, Bethesda, MD, 20814, USA
| | - Irwin Lucki
- Neuroscience Graduate Program, Uniformed Services University, Bethesda, MD, 20814, USA; Department of Pharmacology and Molecular Therapeutics, Uniformed Services University, Bethesda, MD, 20814, USA; Department of Psychiatry, Uniformed Services University, Bethesda, MD, 20814, USA.
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13
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Bonaventura J, Gomez JL, Carlton ML, Lam S, Sanchez-Soto M, Morris PJ, Moaddel R, Kang HJ, Zanos P, Gould TD, Thomas CJ, Sibley DR, Zarate CA, Michaelides M. Target deconvolution studies of (2R,6R)-hydroxynorketamine: an elusive search. Mol Psychiatry 2022; 27:4144-4156. [PMID: 35768639 PMCID: PMC10013843 DOI: 10.1038/s41380-022-01673-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 02/07/2023]
Abstract
The off-label use of racemic ketamine and the FDA approval of (S)-ketamine are promising developments for the treatment of depression. Nevertheless, racemic ketamine and (S)-ketamine are controlled substances with known abuse potential and their use is associated with undesirable side effects. For these reasons, research efforts have focused on identifying alternatives. One candidate is (2R,6R)-hydroxynorketamine ((2R,6R)-HNK), a ketamine metabolite that in preclinical models lacks the dissociative and abuse properties of ketamine while retaining its antidepressant-like behavioral efficacy. (2R,6R)-HNK's mechanism of action however is unclear. The main goals of this study were to perform an in-depth pharmacological characterization of (2R,6R)-HNK at known ketamine targets, to use target deconvolution approaches to discover novel proteins that bind to (2R,6R)-HNK, and to characterize the biodistribution and behavioral effects of (2R,6R)-HNK across several procedures related to substance use disorder liability. We found that unlike (S)- or (R)-ketamine, (2R,6R)-HNK did not directly bind to any known or proposed ketamine targets. Extensive screening and target deconvolution experiments at thousands of human proteins did not identify any other direct (2R,6R)-HNK-protein interactions. Biodistribution studies using radiolabeled (2R,6R)-HNK revealed non-selective brain regional enrichment, and no specific binding in any organ other than the liver. (2R,6R)-HNK was inactive in conditioned place preference, open-field locomotor activity, and intravenous self-administration procedures. Despite these negative findings, (2R,6R)-HNK produced a reduction in immobility time in the forced swim test and a small but significant increase in metabolic activity across a network of brain regions, and this metabolic signature differed from the brain metabolic profile induced by ketamine enantiomers. In sum, our results indicate that (2R,6R)-HNK does not share pharmacological or behavioral profile similarities with ketamine or its enantiomers. However, it could still be possible that both ketamine and (2R,6R)-HNK exert antidepressant-like efficacy through a common and previously unidentified mechanism. Given its pharmacological profile, we predict that (2R,6R)-HNK will exhibit a favorable safety profile in clinical trials, and we must wait for clinical studies to determine its antidepressant efficacy.
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Affiliation(s)
- Jordi Bonaventura
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, 21224, MD, USA
- Departament de Patologia i Terapèutica Experimental, Institut de Neurociències, Universitat de Barcelona, L'Hospitalet de Llobregat, 08907, Catalonia, Spain
| | - Juan L Gomez
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, 21224, MD, USA
| | - Meghan L Carlton
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, 21224, MD, USA
| | - Sherry Lam
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, 21224, MD, USA
| | - Marta Sanchez-Soto
- Molecular Neuropharmacology Section, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, 20892, MD, USA
| | - Patrick J Morris
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Rockville, 20850, MD, USA
| | - Ruin Moaddel
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA
| | - Hye Jin Kang
- National Institute of Mental Health Psychoactive Drug Screening Program, Department of Pharmacology, University of North Carolina Chapel Hill Medical School, Chapel Hill, 27599, NC, USA
| | - Panos Zanos
- Department of Psychology, University of Cyprus, Nicosia, 2109, Cyprus
| | - Todd D Gould
- Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
- Departments of Psychiatry, Pharmacology, and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, 21201, MD, USA
| | - Craig J Thomas
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Rockville, 20850, MD, USA
| | - David R Sibley
- Molecular Neuropharmacology Section, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, 20892, MD, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, Intramural Research Program, Bethesda, 20892, MD, USA
| | - Michael Michaelides
- Biobehavioral Imaging and Molecular Neuropsychopharmacology Unit, National Institute on Drug Abuse Intramural Research Program, Baltimore, 21224, MD, USA.
- Department of Psychiatry & Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, 21205, MD, USA.
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14
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Yost JG, Wulf HA, Browne CA, Lucki I. Antinociceptive and Analgesic Effects of (2 R,6 R)-Hydroxynorketamine. J Pharmacol Exp Ther 2022; 382:256-265. [PMID: 35779947 PMCID: PMC9426759 DOI: 10.1124/jpet.122.001278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/01/2022] [Indexed: 11/22/2022] Open
Abstract
Commonly used pain therapeutics, such as opioid medications, exert dangerous side effects and lack effectiveness in treating some types of pain. Ketamine is also used to treat pain, but side effects limit its widespread use. (2R,6R)-hydroxynorketamine (HNK) is a ketamine metabolite that potentially shares some beneficial behavioral effects of its parent drug without causing significant side effects. This study compared the profile and potential mechanisms mediating the antinociception activity of ketamine and (2R,6R)-HNK in C57BL/6J mice. Additionally, this study compared the reversal of mechanical allodynia by (2R,6R)-HNK with gabapentin in a model of neuropathic pain. Unlike the near-immediate and short-lived antinociception caused by ketamine, (2R,6R)-HNK produced late-developing antinociception 24 hours following administration. Pharmacological blockade of α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid (AMPA) receptors with 2,3-dioxo-6-nitro-7-sulfamoyl-benzo[f]quinoxaline (NBQX) prevented the initiation and expressionof (2R,6R)-HNK antinociception, suggesting the involvement of α-amino-3-hydroxy-5-methyl-4-isoxazole propionic acid receptor-dependent glutamatergic mechanisms in the pain reduction-like responses. Blockade of opioid receptors with naltrexone partially prevented the antinociceptive effect of ketamine but was ineffective against (2R,6R)-HNK. Furthermore, (2R,6R)-HNK did not produce dystaxia, even when tested at doses five times greater than those needed to produce antinociception, indicating a superior safety profile for (2R,6R)-HNK over ketamine. Additionally, (2R,6R)-HNK reversed mechanical allodynia in a spared nerve injury model of neuropathic pain with similar short-term efficacy to gabapentin (within 4 hours) while outperforming gabapentin 24 hours after administration. These findings support the further study of (2R,6R)-HNK as a potentially valuable agent for treating different types of pain and establish certain advantages of (2R,6R)-HNK treatment over ketamine and gabapentin in corresponding assays for pain. SIGNIFICANCE STATEMENT: The ketamine metabolite (2R,6R)-HNK produced antinociception in male and female mice 24 hours after administration via activation of AMPA receptors. The effects of (2R,6R)-HNK differed in time course and mechanism and presented a better safety profile than ketamine. (2R,6R)-HNK also reversed allodynia in SNI-operated animals within 4 hours of treatment onset, with a duration of effect lasting longer than gabapentin. Taken together, (2R,6R)-HNK demonstrates the potential for development as a non-opioid analgesic drug.
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Affiliation(s)
- Jonathan G Yost
- Neuroscience Graduate Program (J.G.Y., C.A.B., I.L.), Department of Pharmacology and Molecular Therapeutics (H.A.W., C.A.B., I.L.), and Department of Psychiatry (I.L.), Uniformed Services University, Bethesda, Maryland
| | - Hildegard A Wulf
- Neuroscience Graduate Program (J.G.Y., C.A.B., I.L.), Department of Pharmacology and Molecular Therapeutics (H.A.W., C.A.B., I.L.), and Department of Psychiatry (I.L.), Uniformed Services University, Bethesda, Maryland
| | - Caroline A Browne
- Neuroscience Graduate Program (J.G.Y., C.A.B., I.L.), Department of Pharmacology and Molecular Therapeutics (H.A.W., C.A.B., I.L.), and Department of Psychiatry (I.L.), Uniformed Services University, Bethesda, Maryland
| | - Irwin Lucki
- Neuroscience Graduate Program (J.G.Y., C.A.B., I.L.), Department of Pharmacology and Molecular Therapeutics (H.A.W., C.A.B., I.L.), and Department of Psychiatry (I.L.), Uniformed Services University, Bethesda, Maryland
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15
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Simons P, Olofsen E, van Velzen M, van Lemmen M, van Dasselaar T, Mohr P, Hammes F, van der Schrier R, Niesters M, Dahan A. S-Ketamine oral thin film—Part 2: Population pharmacodynamics of S-ketamine, S-norketamine and S-hydroxynorketamine. FRONTIERS IN PAIN RESEARCH 2022; 3:946487. [PMID: 36034750 PMCID: PMC9402896 DOI: 10.3389/fpain.2022.946487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/05/2022] [Indexed: 12/17/2022] Open
Abstract
Ketamine is a versatile drug used for many indications and is administered via various routes. Here, we report on the pharmacodynamics of sublingual and buccal fast-dissolving oral-thin-films that contain 50 mg of S-ketamine in a population of healthy male and female volunteers. Twenty volunteers received one or two 50 mg S-ketamine oral thin films in a crossover design, placed for 10 min sublingually (n = 15) or buccally (n = 5). The following measurements were made for 6 h following the film placement: antinociception using three distinct pain assay; electrical, pressure, and heat pain, and drug high on an 11-point visual analog scale. Blood samples were obtained for the measurement of plasma S-ketamine, S-norketamine, and S-hydroxynorketamine concentrations. A population pharmacodynamic analysis was performed in NONMEM to construct a pharmacodynamic model of S-ketamine and its metabolites. P-values < 0.01 were considered significant. The sublingual and buccal 50 and 100 mg S-ketamine oral thin films were antinociceptive and produced drug high with effects lasting 2–6 h, although a clear dose-response relationship for antinociception could not be established. The effects were solely related to the parent compound with no contribution from S-norketamine or S-hydroxynorketamine. S-ketamine potency was lower for antinociception (C50 ranging from 1.2 to 1.7 nmol/mL) than for drug high (C50 0.3 nmol/ml). The onset/offset of effect as defined by the blood-effect-site equilibration half-life did not differ among endpoints and ranged from 0 to 5 min. In conclusion, the 50-mg S-ketamine oral thin film was safe and produced long-term antinociception in all three nociceptive assays with side effects inherent to the use of ketamine. The study was registered at the trial register of the Dutch Cochrane Center (www.trialregister.nl) under identifier NL9267 and the European Union Drug Regulating Authorities Clinical Trials (EudraCT) database under number 2020-005185-33.
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Affiliation(s)
- Pieter Simons
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Maarten van Lemmen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Tom van Dasselaar
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Patrick Mohr
- LTS Lohmann Therapie-Systeme AG, Andernach, Germany
| | | | | | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, Netherlands
- *Correspondence: Albert Dahan
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16
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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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17
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Willis DE, Goldstein PA. Targeting Affective Mood Disorders With Ketamine to Prevent Chronic Postsurgical Pain. FRONTIERS IN PAIN RESEARCH 2022; 3:872696. [PMID: 35832728 PMCID: PMC9271565 DOI: 10.3389/fpain.2022.872696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 06/06/2022] [Indexed: 12/02/2022] Open
Abstract
The phencyclidine-derivative ketamine [2-(2-chlorophenyl)-2-(methylamino)cyclohexan-1-one] was added to the World Health Organization's Model List of Essential Medicines in 1985 and is also on the Model List of Essential Medicines for Children due to its efficacy and safety as an intravenous anesthetic. In sub-anesthetic doses, ketamine is an effective analgesic for the treatment of acute pain (such as may occur in the perioperative setting). Additionally, ketamine may have efficacy in relieving some forms of chronic pain. In 2019, Janssen Pharmaceuticals received regulatory-approval in both the United States and Europe for use of the S-enantiomer of ketamine in adults living with treatment-resistant major depressive disorder. Pre-existing anxiety/depression and the severity of postoperative pain are risk factors for development of chronic postsurgical pain. An important question is whether short-term administration of ketamine can prevent the conversion of acute postsurgical pain to chronic postsurgical pain. Here, we have reviewed ketamine's effects on the biopsychological processes underlying pain perception and affective mood disorders, focusing on non-NMDA receptor-mediated effects, with an emphasis on results from human trials where available.
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Affiliation(s)
- Dianna E. Willis
- Burke Neurological Institute, White Plains, NY, United States
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, NY, United States
| | - Peter A. Goldstein
- Feil Family Brain and Mind Institute, Weill Cornell Medicine, New York, NY, United States
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, United States
- Department of Medicine, Weill Cornell Medicine, New York, NY, United States
- *Correspondence: Peter A. Goldstein
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Moaddel R, Zanos P, Farmer CA, Kadriu B, Morris PJ, Lovett J, Acevedo-Diaz EE, Cavanaugh GW, Yuan P, Yavi M, Thomas CJ, Park LT, Ferrucci L, Gould TD, Zarate CA. Comparative metabolomic analysis in plasma and cerebrospinal fluid of humans and in plasma and brain of mice following antidepressant-dose ketamine administration. Transl Psychiatry 2022; 12:179. [PMID: 35501309 PMCID: PMC9061764 DOI: 10.1038/s41398-022-01941-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 11/25/2022] Open
Abstract
Subanesthetic-dose racemic (R,S)-ketamine (ketamine) produces rapid, robust, and sustained antidepressant effects in major depressive disorder (MDD) and bipolar disorder (BD) and has also been shown to effectively treat neuropathic pain, complex regional pain syndrome, and post-traumatic stress disorder (PTSD). However, to date, its mechanism of action remains unclear. Preclinical studies found that (2 R,6 R;2 S,6 S)-hydroxynorketamine (HNK), a major circulating metabolite of ketamine, elicits antidepressant effects similar to those of ketamine. To help determine how (2 R,6 R)-HNK contributes to ketamine's mechanism of action, an exploratory, targeted, metabolomic analysis was carried out on plasma and CSF of nine healthy volunteers receiving a 40-minute ketamine infusion (0.5 mg/kg). A parallel targeted metabolomic analysis in plasma, hippocampus, and hypothalamus was carried out in mice receiving either 10 mg/kg of ketamine, 10 mg/kg of (2 R,6 R)-HNK, or saline. Ketamine and (2 R,6 R)-HNK both affected multiple pathways associated with inflammatory conditions. In addition, several changes were unique to either the healthy human volunteers and/or the mouse arm of the study, indicating that different pathways may be differentially involved in ketamine's effects in mice and humans. Mechanisms of action found to consistently underlie the effects of ketamine and/or (2 R,6 R)-HNK across both the human metabolome in plasma and CSF and the mouse arm of the study included LAT1, IDO1, NAD+, the nitric oxide (NO) signaling pathway, and sphingolipid rheostat.
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Affiliation(s)
- Ruin Moaddel
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA.
| | - Panos Zanos
- Departments of Psychiatry, Pharmacology, and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, 21201, MD, USA
- Department of Psychology, University of Cyprus, 2109, Nicosia, Cyprus
| | - Cristan A Farmer
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Bashkim Kadriu
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Patrick J Morris
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, 20850, USA
| | - Jacqueline Lovett
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA
| | - Elia E Acevedo-Diaz
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Grace W Cavanaugh
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Peixiong Yuan
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Mani Yavi
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Craig J Thomas
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, 20850, USA
| | - Lawrence T Park
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Luigi Ferrucci
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, 21224, MD, USA
| | - Todd D Gould
- Departments of Psychiatry, Pharmacology, and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, 21201, MD, USA
- Veterans Affairs Maryland Health Care System, Baltimore, MD, 21201, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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19
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Beyond the Raskin Protocol: Ketamine, Lidocaine, and Other Therapies for Refractory Chronic Migraine. Curr Pain Headache Rep 2021; 25:77. [PMID: 34894295 PMCID: PMC8665315 DOI: 10.1007/s11916-021-00992-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 10/31/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to discuss the available evidence and therapeutic considerations for intravenous drug therapy for refractory chronic migraine. RECENT FINDINGS In carefully monitored settings, the inpatient administration of intravenous lidocaine and ketamine can be successful in treating refractory chronic migraine. Many patients with refractory chronic migraine have experienced treatment failure with the Raskin protocol. The use of aggressive inpatient infusion therapy consisting of intravenous lidocaine or ketamine, along with other adjunctive medications, has become increasingly common for these patients when all other treatments have failed. There is a clear need for prospective studies in this population comprised of patients who have largely been excluded from other studies.
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20
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van Velzen M, Dahan JD, van Dorp EL, Mogil JS, Hooijmans CR, Dahan A. Efficacy of ketamine in relieving neuropathic pain: a systematic review and meta-analysis of animal studies. Pain 2021; 162:2320-2330. [PMID: 33790195 PMCID: PMC8374709 DOI: 10.1097/j.pain.0000000000002231] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/21/2021] [Accepted: 02/01/2021] [Indexed: 12/09/2022]
Abstract
ABSTRACT In humans, proof of long-term efficacy of ketamine treatment in neuropathic pain is lacking. To improve our understanding of ketamine behavior under various administration conditions, we performed a systematic review and meta-analyses of controlled studies on the efficacy of ketamine in mice and rats with a disease model of nerve injury on relief of allodynia. Searches in PubMed and EMBASE identified 31 unique studies. Four meta-analyses were conducted. The first analysis included 19 comparisons on a single ketamine dose and measurement of effect within 3 hours of dosing and showed an appreciable effect (standardized mean difference 1.6, 95% confidence interval 1.1-2.1). Subgroup analyses showed no effect of species, administration route, or dose. A single administration was insufficient to sustain relief of allodynia at 24 or 72 hours after dosing, as observed in our second analysis (7 comparisons) with similar effects in ketamine-treated and control animals. Chronic ketamine administration (9 comparisons) caused profound relief of allodynia when tested during ketamine exposure (effect size 5.1, 3.7-6.5). The final analysis (6 comparisons) showed that chronic administration caused a slow loss of relief of allodynia with 70% loss of effect 24 days after end of treatment. No subgroups analyses were possible in the last 3 meta-analyses due to small group sizes. These results indicate long-term ketamine anti-allodynic effects after chronic exposure (>3 days) but not after a single administration. Given several limitations, extrapolation of the animal data to the human condition is tenuous.
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Affiliation(s)
- Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jack D.C. Dahan
- Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Eveline L.A van Dorp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeffrey S. Mogil
- Department of Psychology and Anesthesia, McGill University, Montreal, Canada
| | - Carlijn R. Hooijmans
- Department of Health Evidence unit SYRCLE and Department of Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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21
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Schwenk ES, Pradhan B, Nalamasu R, Stolle L, Wainer IW, Cirullo M, Olsen A, Pergolizzi JV, Torjman MC, Viscusi ER. Ketamine in the Past, Present, and Future: Mechanisms, Metabolites, and Toxicity. Curr Pain Headache Rep 2021; 25:57. [PMID: 34269883 DOI: 10.1007/s11916-021-00977-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE OF REVIEW While ketamine's analgesia has mostly been attributed to antagonism of N-methyl-D-aspartate receptors, evidence suggests multiple other pathways are involved in its antidepressant and possibly analgesic activity. These mechanisms and ketamine's role in the nociplastic pain paradigm are discussed. Animal studies demonstrating ketamine's neurotoxicity have unclear human translatability and findings from key rodent and human studies are presented. RECENT FINDINGS Ketamine's metabolites, and (2R,6R)-hydroxynorketamine in particular, may play a greater role in its clinical activity than previously believed. The activation of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and the mammalian target of rapamycin by ketamine are mechanisms that are still being elucidated. Ketamine might work best in nociplastic pain, which involves altered pain processing. While much is known about ketamine, new studies will continue to define its role in clinical medicine. Evidence supporting ketamine's neurotoxicity in humans is lacking and should not impede future ketamine clinical trials.
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Affiliation(s)
- Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA.
| | - Basant Pradhan
- Psychiatry & Pediatrics, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Rohit Nalamasu
- Department of Physical Medicine and Rehabilitation, University of Nebraska Medical Center, Omaha, NE, USA
| | | | | | - Michael Cirullo
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alexander Olsen
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | | | - Marc C Torjman
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
| | - Eugene R Viscusi
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, 111 South 11th Street, Gibbon Building, 8290, Philadelphia, PA, 19107, USA
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22
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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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23
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Schwenk ES, Torjman MC, Moaddel R, Lovett J, Katz D, Denk W, Lauritsen C, Silberstein SD, Wainer IW. Ketamine for Refractory Chronic Migraine: An Observational Pilot Study and Metabolite Analysis. J Clin Pharmacol 2021; 61:1421-1429. [PMID: 34125442 DOI: 10.1002/jcph.1920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/02/2021] [Indexed: 11/08/2022]
Abstract
Patients with refractory chronic migraine have substantial disability and have failed many acute and preventive medications. When aggressive intravenous therapy is indicated, both lidocaine and (R,S)-ketamine infusions have been used successfully to provide relief. Retrospective studies have shown that both agents may be associated with short-term analgesia. In this prospective, observational pilot study of 6 patients, we compared the effects of lidocaine and (R,S)-ketamine infusions and performed metabolite analyses of (R,S)-ketamine to determine its metabolic profile in this population. One of (R,S)-ketamine's metabolites, (2R,6R)-hydroxynorketamine, has been shown in animal studies to reduce pain, but human studies in patients undergoing continuous (R,S)-ketamine infusions for migraine are lacking. All 6 patients tolerated both infusions well with mild adverse effects. The baseline mean pain rating (0-10 numeric rating scale) decreased from 7.5 ± 2.2 to 4.7 ± 2.8 by end of lidocaine treatment ( P ≤ . 05 ) but increased to 7.0 ± 1.4 by the postdischarge visit at 4 weeks (P > .05 vs baseline). The baseline mean pain rating prior to ketamine treatment was 7.4 ± 1.4, which decreased to 3.7 ± 2.3 by the end of the hospitalization ( P ≤ . 05 ) but increased to 7.2 ± 1.7 by the postdischarge visit at 6 weeks (P > .05 vs baseline). For the primary outcome the change in pain from baseline to end of treatment was greater for ketamine than lidocaine (-3.7 vs -2.8; P ≤ . 05 ), but this has minimal clinical significance. Ketamine metabolite analysis revealed that (2R,6R)-hydroxynorketamine was the predominant metabolite during most of the infusion, consistent with previous studies.
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Affiliation(s)
- Eric S Schwenk
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Marc C Torjman
- Department of Anesthesiology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ruin Moaddel
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland, USA
| | - Jacqueline Lovett
- National Institute on Aging, National Institutes of Health, Baltimore, Maryland, USA
| | - Daniel Katz
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William Denk
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clinton Lauritsen
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stephen D Silberstein
- Department of Neurology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Irving W Wainer
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
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24
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Chiral Pharmacokinetics and Metabolite Profile of Prolonged-release Ketamine Tablets in Healthy Human Subjects. Anesthesiology 2021; 135:326-339. [PMID: 34019627 DOI: 10.1097/aln.0000000000003829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The anesthetic ketamine after intravenous dosing is nearly completely metabolized to R- and S-stereoisomers of the active norketamine (analgesic, psychoactive) and 2,6-hydroxynorketamine (potential analgesic, antidepressant) as well as the inactive dehydronorketamine. Oral administration favors the formation of 2,6-hydroxynorketamines via extensive presystemic metabolism. The authors hypothesized that plasma exposure to 2,6-hydroxynorketamines relative to the psychoactive ketamine is greater after prolonged-release ketamine tablets than it is after intravenous ketamine. METHODS Pharmacokinetics of ketamine after intravenous infusion (5.0 mg) and single-dose administrations of 10, 20, 40, and 80 mg prolonged-released tablets were evaluated in 15 healthy white human subjects by means of a controlled, ascending-dose study. The stereoisomers of ketamine and metabolites were quantified in serum and urine by validated tandem mass-spectrometric assays and evaluated by noncompartmental pharmacokinetic analysis. RESULTS After 40 mg prolonged-release tablets, the mean ± SD area under the concentrations-time curve ratios for 2,6-hydroxynorketamine/ketamine were 18 ± 11 (S-stereoisomers) and 30 ± 16 (R-stereoisomers) compared to 1.7 ± 0.8 and 3.1 ± 1.4 and after intravenous infusion (both P < 0.001). After 10 and 20 mg tablets, the R-ratios were even greater. The distribution volumes at steady state of S- and R-ketamine were 6.6 ± 2.2 and 5.6 ± 2.1 l/kg, terminal half-lives 5.2 ± 3.4 and 6.1 ± 3.1 h, and metabolic clearances 1,620 ± 380 and 1,530 ± 380 ml/min, respectively. Bioavailability of the 40 mg tablets was 15 ± 8 (S-isomer) and 19 ± 10% (R-isomer) and terminal half-life 11 ± 4 and 10 ± 4 h. About 7% of the dose was renally excreted as S-stereoisomers and 17% as R-stereoisomers. CONCLUSIONS Prolonged-release ketamine tablets generate a high systemic exposure to 2,6-hydroxynorketamines and might therefore be an efficient and safer pharmaceutical dosage form for treatment of patients with chronic neuropathic pain compared to intravenous infusion. EDITOR’S PERSPECTIVE
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25
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Highland JN, Zanos P, Riggs LM, Georgiou P, Clark SM, Morris PJ, Moaddel R, Thomas CJ, Zarate CA, Pereira EFR, Gould TD. Hydroxynorketamines: Pharmacology and Potential Therapeutic Applications. Pharmacol Rev 2021; 73:763-791. [PMID: 33674359 PMCID: PMC7938660 DOI: 10.1124/pharmrev.120.000149] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hydroxynorketamines (HNKs) are formed in vivo after (R,S)-ketamine (ketamine) administration. The 12 HNK stereoisomers are distinguished by the position of cyclohexyl ring hydroxylation (at the 4, 5, or 6 position) and their unique stereochemistry at two stereocenters. Although HNKs were initially classified as inactive metabolites because of their lack of anesthetic effects, more recent studies have begun to reveal their biologic activities. In particular, (2R,6R)- and (2S 6)-HNK exert antidepressant-relevant behavioral and physiologic effects in preclinical models, which led to a rapid increase in studies seeking to clarify the mechanisms by which HNKs exert their pharmacological effects. To date, the majority of HNK research has focused on the actions of (2R,6R)-HNK because of its robust behavioral actions in tests of antidepressant effectiveness and its limited adverse effects. This review describes HNK pharmacokinetics and pharmacodynamics, as well as the putative cellular, molecular, and synaptic mechanisms thought to underlie their behavioral effects, both following their metabolism from ketamine and after direct administration in preclinical studies. Converging preclinical evidence indicates that HNKs modulate glutamatergic neurotransmission and downstream signaling pathways in several brain regions, including the hippocampus and prefrontal cortex. Effects on other neurotransmitter systems, as well as possible effects on neurotrophic and inflammatory processes, and energy metabolism, are also discussed. Additionally, the behavioral effects of HNKs and possible therapeutic applications are described, including the treatment of unipolar and bipolar depression, post-traumatic stress disorder, chronic pain, neuroinflammation, and other anti-inflammatory and analgesic uses. SIGNIFICANCE STATEMENT: Preclinical studies indicate that hydroxynorketamines (HNKs) exert antidepressant-relevant behavioral actions and may also have analgesic, anti-inflammatory, and other physiological effects that are relevant for the treatment of a variety of human diseases. This review details the pharmacokinetics and pharmacodynamics of the HNKs, as well as their behavioral actions, putative mechanisms of action, and potential therapeutic applications.
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Affiliation(s)
- Jaclyn N Highland
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Panos Zanos
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Lace M Riggs
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Polymnia Georgiou
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Sarah M Clark
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Patrick J Morris
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Ruin Moaddel
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Craig J Thomas
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Carlos A Zarate
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Edna F R Pereira
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
| | - Todd D Gould
- Departments of Psychiatry (J.N.H., P.Z., L.M.R., P.G., S.M.C., T.D.G.), Pharmacology (P.Z., T.D.G.), Physiology (P.Z.), Anatomy and Neurobiology (T.D.G), Epidemiology and Public Health, Division of Translational Toxicology (E.F.R.P.), Programs in Toxicology (J.N.H.) and Neuroscience (L.M.R.), and Veterans Affairs Maryland Health Care System, University of Maryland School of Medicine, Baltimore, Maryland (T.D.G.); Division of Preclinical Innovation, National Center for Advancing Translational Sciences, Intramural Research Program, National Institutes of Health, Rockville, Maryland (P.J.M., C.J.T.); Biomedical Research Center, National Institute on Aging, Intramural Research Program, National Institutes of Health, Baltimore, Maryland (R.M.); Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland (C.A.Z.)
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Kamp J, Jonkman K, van Velzen M, Aarts L, Niesters M, Dahan A, Olofsen E. Pharmacokinetics of ketamine and its major metabolites norketamine, hydroxynorketamine, and dehydronorketamine: a model-based analysis. Br J Anaesth 2020; 125:750-761. [PMID: 32838982 DOI: 10.1016/j.bja.2020.06.067] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 05/27/2020] [Accepted: 06/19/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Recent studies show activity of ketamine metabolites, such as hydroxynorketamine, in producing rapid relief of depression-related symptoms and analgesia. To improve our understanding of the pharmacokinetics of ketamine and metabolites norketamine, dehydronorketamine, and hydroxynorketamine, we developed a population pharmacokinetic model of ketamine and metabolites after i.v. administration of racemic ketamine and the S-isomer (esketamine). Pharmacokinetic data were derived from an RCT on the efficacy of sodium nitroprusside (SNP) in reducing the psychotomimetic side-effects of ketamine in human volunteers. METHODS Three increasing i.v. doses of esketamine and racemic ketamine were administered to 20 healthy volunteers, and arterial plasma samples were obtained for measurement of ketamine and metabolites. Subjects were randomised to receive esketamine/SNP, esketamine/placebo, racemic ketamine/SNP, and racemic ketamine/placebo on four separate occasions. The time-plasma concentration data of ketamine and metabolites were analysed using a population compartmental model approach. RESULTS The pharmacokinetics of ketamine and metabolites were adequately described by a seven-compartment model with two ketamine, norketamine, and hydroxynorketamine compartments and one dehydronorketamine compartment with metabolic compartments in-between ketamine and norketamine, and norketamine and dehydronorketamine main compartments. Significant differences were found between S- and R-ketamine enantiomer pharmacokinetics, with up to 50% lower clearances for the R-enantiomers, irrespective of formulation. Whilst SNP had a significant effect on ketamine clearances, simulations showed only minor effects of SNP on total ketamine pharmacokinetics. CONCLUSIONS The model is of adequate quality for use in future pharmacokinetic and pharmacodynamic studies into the efficacy and side-effects of ketamine and metabolites. CLINICAL TRIAL REGISTRATION Dutch Cochrane Center 5359.
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Affiliation(s)
- Jasper Kamp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands.
| | - Kelly Jonkman
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leon Aarts
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
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Farmer CA, Gilbert JR, Moaddel R, George J, Adeojo L, Lovett J, Nugent AC, Kadriu B, Yuan P, Gould TD, Park LT, Zarate CA. Ketamine metabolites, clinical response, and gamma power in a randomized, placebo-controlled, crossover trial for treatment-resistant major depression. Neuropsychopharmacology 2020; 45:1398-1404. [PMID: 32252062 PMCID: PMC7297997 DOI: 10.1038/s41386-020-0663-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 03/10/2020] [Accepted: 03/19/2020] [Indexed: 12/27/2022]
Abstract
A single, subanesthetic dose of (R,S)-ketamine (ketamine) exerts rapid and robust antidepressant effects. Several groups previously reported that (2S,6S;2R,6R)-hydroxynorketamine (HNK) had antidepressant effects in rodents, and that (2R,6R)-HNK increased cortical electroencephalographic gamma power. This exploratory study examined the relationship between ketamine metabolites, clinical response, psychotomimetic symptoms, and gamma power changes in 34 individuals (ages 18-65) with treatment-resistant depression (TRD) who received a single ketamine infusion (0.5 mg/kg) over 40 min. Plasma concentrations of ketamine, norketamine, and HNKs were measured at 40, 80, 120, and 230 min and at 1, 2, and 3 days post-infusion. Linear mixed models evaluated ketamine metabolites as mediators of antidepressant and psychotomimetic effects and their relationship to resting-state whole-brain magnetoencephalography (MEG) gamma power 6-9 h post-infusion. Three salient findings emerged. First, ketamine concentration positively predicted distal antidepressant response at Day 11 post-infusion, and an inverse relationship was observed between (2S,6S;2R,6R)-HNK concentration and antidepressant response at 3 and 7 days post-infusion. Norketamine concentration was not associated with antidepressant response. Second, ketamine, norketamine, and (2S,6S;2R,6R)-HNK concentrations at 40 min were positively associated with contemporaneous psychotomimetic symptoms; post-hoc analysis revealed that ketamine was the predominant contributor. Third, increased (2S,6S;2R,6R)-HNK maximum observed concentration (Cmax) was associated with increased MEG gamma power. While contrary to preclinical observations and our a priori hypotheses, these exploratory results replicate those of a recently published study documenting a relationship between higher (2S,6S;2R,6R)-HNK concentrations and weaker antidepressant response in humans and provide further rationale for studying gamma power changes as potential biomarkers of antidepressant response.
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Affiliation(s)
- Cristan A Farmer
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Jessica R Gilbert
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Ruin Moaddel
- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Jomy George
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - Lilian Adeojo
- Clinical Pharmacokinetics Research Unit, Pharmacy Department, National Institutes of Health, Bethesda, MD, USA
| | - Jacqueline Lovett
- National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Allison C Nugent
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
- Magnetoencephalography Core Facility, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Bashkim Kadriu
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Peixiong Yuan
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Todd D Gould
- Departments of Psychiatry, Pharmacology, and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
- Veterans Affairs Maryland Health Care System, Baltimore, MD, USA
| | - Lawrence T Park
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
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Kamp J, Van Velzen M, Olofsen E, Boon M, Dahan A, Niesters M. Pharmacokinetic and pharmacodynamic considerations for NMDA-receptor antagonist ketamine in the treatment of chronic neuropathic pain: an update of the most recent literature. Expert Opin Drug Metab Toxicol 2019; 15:1033-1041. [DOI: 10.1080/17425255.2019.1689958] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Jasper Kamp
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique Van Velzen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Erik Olofsen
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn Boon
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marieke Niesters
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
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Das V, Kroin JS, Moric M, McCarthy RJ, Buvanendran A. Antihyperalgesia effect of AMP-activated protein kinase (AMPK) activators in a mouse model of postoperative pain. Reg Anesth Pain Med 2019; 44:rapm-2019-100651. [PMID: 31229963 DOI: 10.1136/rapm-2019-100651] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/21/2019] [Accepted: 05/29/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND OBJECTIVES AMP-activated protein kinase (AMPK) activator drugs decrease hypersensitivity in mice with pain. This study examines if postsurgery treatment with the prototype AMPK activator metformin and a new mechanism-specific AMPK activator, O304, after plantar hindpaw incision in mice, would reduce mechanical hypersensitivity and produce changes in the AMPK pathway in the dorsal root ganglion (DRG). METHODS To create postoperative pain, an incision was made in the left plantar hindpaw. Animals were randomized into four oral gavage drug treatment groups (n=8/group): (1) vehicle, (2) metformin 200 mg/kg, (3) O304 200 mg/kg and (4) O304 200 mg/kg plus metformin 200 mg/kg. Drug gavages were performed 4 hours postsurgery and were repeated for 3 days. Mechanical hypersensitivity was measured with von Frey filaments. Changes in phosphorylated AMP-activated protein kinase alpha subunit, phosphorylated mechanistic target of rapamycin and phosphorylated eukaryotic initiation factor 2 alpha in DRG neurons were examined by immunohistochemistry. RESULTS O304 or metformin increased von Frey thresholds (reduced mechanical hypersensitivity) in plantar incision mice versus vehicle-treated incision mice between days 1 and 4 (difference of mean area under the curve, O304: 2.24 g*day; 95% CI of the difference 0.28 to 4.21, p=0.011; metformin: 2.56 g*day; 95% CI of the difference 1.71 to 3.41, p<0.001). The drug combination further elevated von Frey thresholds. In the vehicle-treated group, the AMP-activated protein kinase alpha subunit was downregulated and mechanistic target of rapamycin and eukaryotic initiation factor 2 alpha were upregulated in DRG neurons; these deficits were reversed by the AMPK activator treatments. CONCLUSIONS Early treatment with the mechanism-specific AMPK activator O304 or the prototype AMPK activator metformin reduces mechanical hypersensitivity in a postoperative pain model in mice. These drugs also normalize the AMPK pathway in the DRG.
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Affiliation(s)
- Vaskar Das
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Jeffrey S Kroin
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Mario Moric
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert J McCarthy
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Asokumar Buvanendran
- Department of Anesthesiology, Rush University Medical Center, Chicago, Illinois, USA
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Abstract
For decades, symptoms of depression have been treated primarily with medications that directly target the monoaminergic brain systems, which typically take weeks to exert measurable effects and months to exert remission of symptoms. Low, subanesthetic doses of ( R,S)-ketamine (ketamine) result in the rapid improvement of core depressive symptoms, including mood, anhedonia, and suicidal ideation, occurring within hours following a single administration, with relief from symptoms typically lasting up to a week. The discovery of these actions of ketamine has resulted in a reconceptualization of how depression could be more effectively treated in the future. In this review, we discuss clinical data pertaining to ketamine and other rapid-acting antidepressant drugs, as well as the current state of pharmacological knowledge regarding their mechanism of action. Additionally, we discuss the neurobiological circuits that are engaged by this drug class and that may be targeted by a future generation of medications, for example, hydroxynorketamine; metabotropic glutamate receptor 2/3 antagonists; and N-methyl-d-aspartate, α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid, and γ-aminobutyric acid receptor modulators.
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Affiliation(s)
- Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA;
- Departments of Pharmacology and Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
| | - Carlos A Zarate
- Experimental Therapeutics and Pathophysiology Branch, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland, USA 20892
| | - Scott M Thompson
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA;
- Department of Physiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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Highland JN, Morris PJ, Zanos P, Lovett J, Ghosh S, Wang AQ, Zarate CA, Thomas CJ, Moaddel R, Gould TD. Mouse, rat, and dog bioavailability and mouse oral antidepressant efficacy of ( 2R,6R)-hydroxynorketamine. J Psychopharmacol 2019; 33:12-24. [PMID: 30488740 PMCID: PMC6541551 DOI: 10.1177/0269881118812095] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND (R,S)-ketamine has gained attention for its rapid-acting antidepressant actions in patients with treatment-resistant depression. However, widespread use of ketamine is limited by its side effects, abuse potential, and poor oral bioavailability. The ketamine metabolite, (2R,6R)-hydroxynorketamine, exerts rapid antidepressant effects, without ketamine's adverse effects and abuse potential, in rodents. METHODS We evaluated the oral bioavailability of (2R,6R)-hydroxynorketamine in three species (mice, rats, and dogs) and also evaluated five candidate prodrug modifications for their capacity to enhance the oral bioavailability of (2R,6R)-hydroxynorketamine in mice. Oral administration of (2R,6R)-hydroxynorketamine was assessed for adverse behavioral effects and for antidepressant efficacy in the mouse forced-swim and learned helplessness tests. RESULTS (2R,6R)-hydroxynorketamine had absolute bioavailability between 46-52% in mice, 42% in rats, and 58% in dogs. Compared to intraperitoneal injection in mice, the relative oral bioavailability of (2R,6R)-hydroxynorketamine was 62%, which was not improved by any of the candidate prodrugs tested. Following oral administration, (2R,6R)-hydroxynorketamine readily penetrated the brain, with brain to plasma ratios between 0.67-1.2 in mice and rats. Oral administration of (2R,6R)-hydroxynorketamine to mice did not alter locomotor activity or precipitate behaviors associated with discomfort, sickness, or stereotypy up to a dose of 450 mg/kg. Oral (2R,6R)-hydroxynorketamine reduced forced-swim test immobility time (15-150 mg/kg) and reversed learned helplessness (50-150 mg/kg) in mice. CONCLUSIONS These results demonstrate that (2R,6R)-hydroxynorketamine has favorable oral bioavailability in three species and exhibits antidepressant efficacy following oral administration in mice.
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Affiliation(s)
- Jaclyn N Highland
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA,Program in Toxicology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Patrick J Morris
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, USA
| | - Panos Zanos
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jacqueline Lovett
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Soumita Ghosh
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Amy Q Wang
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, USA
| | - Carlos A Zarate
- Section on the Neurobiology and Treatment of Mood Disorders, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Craig J Thomas
- Division of Preclinical Innovation, National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, USA
| | - Ruin Moaddel
- Biomedical Research Center, National Institute on Aging, National Institutes of Health, Baltimore, MD, USA
| | - Todd D Gould
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA,Department of Pharmacology, University of Maryland School of Medicine, Baltimore, MD, USA,Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD, USA
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