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Vos CF, Hemminga WL, Aarnoutse RE, Ruhé HG. Increasing the bioavailability of oral esketamine by a single dose of cobicistat: A case study. Pharmacotherapy 2024; 44:480-484. [PMID: 38819020 DOI: 10.1002/phar.2942] [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: 06/11/2023] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/01/2024]
Abstract
AbstractBackgroundIntranasal esketamine is an approved drug for treatment‐resistant depression (TRD); however, it is costly and may result in specific adverse effects. In this single case study, we explored if oral esketamine can be a suitable alternative.MethodsIn collaboration with a 39‐year‐old female with TRD, we compared plasma concentration curves of intranasal (84 mg) and oral (1, 2 and 4 mg/kg) esketamine. Because oral esketamine has a relatively low bioavailability, it results in a different ratio between esketamine and its primary metabolite noresketamine. To increase the bioavailability of oral esketamine, we co‐administered a single dose of the cytochrome P‐450 (CYP) 3A4 inhibitor cobicistat (150 mg).ResultsFor all doses administered, oral esketamine resulted in lower esketamine but higher noresketamine peak plasma concentrations compared with intranasal treatment. Using oral esketamine it was not possible to generate a similar esketamine plasma concentration curve as with the intranasal treatment, except when combined with cobicistat (esketamine 2 mg/kg plus cobicistat 150 mg).ConclusionsOur findings demonstrate that cobicistat effectively increases the bioavailability of oral esketamine. Further research is required in a larger population, especially to investigate the clinical benefit of cobicistat as a booster drug for oral esketamine.
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Affiliation(s)
- Cornelis F Vos
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wietske L Hemminga
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Henricus G Ruhé
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
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Smith-Apeldoorn SY, Veraart JKE, Kamphuis J, Spijker J, van der Meij A, van Asselt ADI, Aan Het Rot M, Schoevers RA. Oral esketamine in patients with treatment-resistant depression: a double-blind, randomized, placebo-controlled trial with open-label extension. Mol Psychiatry 2024:10.1038/s41380-024-02478-9. [PMID: 38523183 DOI: 10.1038/s41380-024-02478-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 01/23/2024] [Accepted: 02/05/2024] [Indexed: 03/26/2024]
Abstract
About one-third of patients with depression do not achieve adequate response to current treatment options. Although intravenous and intranasal administrations of (es)ketamine have shown antidepressant properties, their accessibility and scalability are limited. We investigated the efficacy, safety, and tolerability of generic oral esketamine in patients with treatment-resistant depression (TRD) in a randomized placebo-controlled trial with open-label extension. This study consisted of 1) a six-week fixed low-dose treatment phase during which 111 participants received oral esketamine 30 mg or placebo three times a day; 2) a four-week wash-out phase; and 3) an optional six-week open-label individually titrated treatment phase during which participants received 0.5 to 3.0 mg/kg oral esketamine two times a week. The primary outcome measure was change in depressive symptom severity, assessed with the Hamilton Depression Rating Scale (HDRS17), from baseline to 6 weeks. Fixed low-dose oral esketamine when compared to placebo had no benefit on the HDRS17 total score (p = 0.626). Except for dizziness and sleep hallucinations scores, which were higher in the esketamine arm, we found no significant difference in safety and tolerability aspects. During the open-label individually titrated treatment phase, the mean HDRS17 score decreased from 21.0 (SD 5.09) to 15.1 (SD 7.27) (mean difference -6.0, 95% CI -7.71 to -4.29, p < 0.001). Our results suggest that fixed low-dose esketamine is not effective in TRD. In contrast, individually titrated higher doses of oral esketamine might have antidepressant properties.
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Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jolien K E Veraart
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Psychiatry, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine Kamphuis
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Spijker
- Depression Expertise Center, Pro Persona Mental Health Care, Nijmegen, The Netherlands
- Behavioral Science Institute, Radboud University, Nijmegen, The Netherlands
| | | | - Antoinette D I van Asselt
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marije Aan Het Rot
- Department of Psychology, University of Groningen, Groningen, The Netherlands
- School of Behavioral and Cognitive Neurosciences, University of Groningen, Groningen, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- School of Behavioral and Cognitive Neurosciences, University of Groningen, Groningen, The Netherlands
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3
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d'Andrea G, Pettorruso M, Di Lorenzo G, Rhee TG, Chiappini S, Carullo R, Barlati S, Zanardi R, Rosso G, Di Nicola M, Andriola I, Marcatili M, Clerici M, Dell'Osso BM, Sensi SL, Mansur RB, Rosenblat JD, Martinotti G, McIntyre RS. The rapid antidepressant effectiveness of repeated dose of intravenous ketamine and intranasal esketamine: A post-hoc analysis of pooled real-world data. J Affect Disord 2024; 348:314-322. [PMID: 38145840 DOI: 10.1016/j.jad.2023.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/30/2023] [Accepted: 12/13/2023] [Indexed: 12/27/2023]
Abstract
INTRODUCTION Intravenous ketamine (KET-IV) and intranasal esketamine (ESK-NS) are effective in the acute treatment of Treatment-Resistant Depression (TRD). Studies comparing KET-IV and ESK-NS concerning their action, safety, and tolerability are currently lacking. MATERIALS AND METHODS We combined patients' data from two unipolar TRD cohorts that received KET-IV (n = 171) at the Canadian Rapid Treatment Center of Excellence in Toronto, Canada, or ESK-NS (n = 140) at several TRD clinics in Italy. The Quick Inventory for Depression Symptomatology-Self-Report-16/QIDS-SR16 in the KET-IV group and Montgomery-Åsberg Depression Rating Scale/MADRS in the ESK-NS group measured depressive symptoms at baseline (T0) and after the acute treatment phase (T1) (i.e., four infusions of KET-IV and eight administrations of ESK-NS). As different scales were used, the primary outcome was to compare the improvement in depression severity in the two cohorts by measuring effect sizes, response and remission rates. Finally, we compare side effects and discontinuation rates. RESULTS At T1, KET-IV and ESK-NS significantly reduced depressive symptoms (respectively: QIDS-SR16 mean reduction = 5.65, p < 0.001; MADRS mean reduction = 11.41, p = 0.025). KET-IV showed larger effect sizes compared to ESK-NS (1.666 vs. 1.244). KET-IV had higher response rates (36 % vs. 25 %; p = 0.042) but not superior remission rates (13 % vs. 12 %; p = 0.845) than ESK-NS at T1. Despite more reported side effects, KET-IV did not cause more discontinuations for adverse events (4.6 % vs. 2.12 %; p = 0.228) than ESK-NS. CONCLUSION KET-IV showed a higher short-term antidepressant effect, whereas ESK-NS exhibited lower side effects. Both were generally well tolerated. Future head-to-head studies should consider the long-term efficacy of these treatments.
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Affiliation(s)
- Giacomo d'Andrea
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Mauro Pettorruso
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Giorgio Di Lorenzo
- Chair of Psychiatry, Department of Systems Medicine, Tor Vergata University of Rome, Rome, Italy; IRCCS Fondazione Santa Lucia, Rome, Italy
| | - Taeho Greg Rhee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA; VA New England Mental Illness, Research, Education and Clinical Center (MIRECC), VA Connecticut Healthcare System, West Haven, CT, USA; Department of Public Health Sciences, School of Medicine, University of Connecticut, Farmington, CT, USA
| | - Stefania Chiappini
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Rosalba Carullo
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Brescia, Italy
| | - Raffaella Zanardi
- Mood Disorder Unit, Department of Clinical Neurosciences, IRCCS San Raffaele Scientific Institute, Milan, Italy; Department of Clinical Neurosciences, University Vita-Salute San Raffaele, Milan, Italy
| | - Gianluca Rosso
- Department of Neurosciences Rita Levi Montalcini, University of Torino, Turin, Italy
| | - Marco Di Nicola
- Department of Neurosciences, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome; Department of Psychiatry, Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Rome, Italy
| | | | - Matteo Marcatili
- Department of Mental Health and Addiction, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Massimo Clerici
- Department of Mental Health and Addiction, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Bernardo Maria Dell'Osso
- Department of Biomedical and Clinical Sciences Luigi Sacco and Aldo Ravelli Center for Neurotechnology and Brain Therapeutic, University of Milan, Milano, Italy
| | - Stefano L Sensi
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Braxia Health, Canadian Centre for Rapid Treatment Excellence (CRTCE), Mississauga, ON, Canada
| | - Giovanni Martinotti
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy; Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Braxia Health, Canadian Centre for Rapid Treatment Excellence (CRTCE), Mississauga, ON, Canada.
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K Freind JM, Beserra FR, Menezes BS, Mograbi DC. Therapeutic Protocols Using Ketamine and Esketamine for Depressive Disorders: A Systematic Review. J Psychoactive Drugs 2023:1-17. [PMID: 37638529 DOI: 10.1080/02791072.2023.2248989] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/10/2023] [Indexed: 08/29/2023]
Abstract
Depression is one of the most prevalent mental health disorders globally, causing severe emotional suffering, reducing life expectancy and increasing the risk of suicide. Recently, the use of dissociative psychedelic substances such as ketamine and esketamine for depressive disorders has expanded treatment options. We sought to analyze, through a systematic review, the existing protocols for the treatment of depression with ketamine and esketamine. The search adopted PRISMA criteria and was performed using PubMed and Web of Science databases. Procedures in each study were compared, focusing on the sample recruited, therapeutic approaches, including the clinical team and professionals engaged in treatment, medical procedures, description of the setting (including music) and factors such as specific medication (ketamine or esketamine), route of administration and dosage employed. Results indicated the predominance of a medical approach, with a limited number of studies on ketamine assisted psychotherapy (KAP) and other modalities of psychedelic assisted therapy. Additionally, there is limited information on psychosocial elements such as preparation, psychological support during session and integration of experience. Altogether these findings suggest that treatment of depression with ketamine or esketamine diverges in relation to the practices employed with psychedelic substances. This is discussed considering future research directions in the field.
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Affiliation(s)
- Julia M K Freind
- Department of Psychology, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de janeiro, Brazil
| | - Fernando R Beserra
- Department of Psychology, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de janeiro, Brazil
| | - Bruno S Menezes
- Institute of Psychiatry, Federal University of Rio de Janeiro (UFRJ), Rio de janeiro, Brazil
| | - Daniel C Mograbi
- Department of Psychology, Pontifical Catholic University of Rio de Janeiro (PUC-Rio), Rio de janeiro, Brazil
- Institute of Psychiatry,Psychology & Neuroscience, King's College London, London, UK
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5
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Tang Y, Liu Y, Zhou H, Lu H, Zhang Y, Hua J, Liao X. Esketamine is neuroprotective against traumatic brain injury through its modulation of autophagy and oxidative stress via AMPK/mTOR-dependent TFEB nuclear translocation. Exp Neurol 2023; 366:114436. [PMID: 37187276 DOI: 10.1016/j.expneurol.2023.114436] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/05/2023] [Accepted: 05/11/2023] [Indexed: 05/17/2023]
Abstract
Recent clinical studies highlight the neuroprotective effects of esketamine, but its benefits following traumatic brain injury (TBI) have not been defined. Here, we investigated the effects of esketamine following TBI and its associated neuroprotection mechanisms. In our study, controlled cortical impact injury on mice was utilized to induce the TBI model in vivo. TBI mice were randomized to receive vehicle or esketamine at 2 h post-injury for 7 consecutive days. Neurological deficits and brain water content in mice were detected, respectively. Cortical tissues surrounding focal trauma were obtained for Nissl staining, immunofluorescence, immunohistochemistry, and ELISA assay. In vitro, esketamine were added in culture medium after cortical neuronal cells induced by H2O2 (100μM). After exposed for 12h, neuronal cells were obtained for western blotting, immunofluorescence, ELISA and CO-IP assay. Following administration of 2-8 mg/kg esketamine, we observed that 8 mg/kg esketamine produced no additional recovery of neurological function and ability to alleviate brain edema in TBI mice model, so 4 mg/kg esketamine was selected for subsequent experiments. Additionally, esketamine can effectively reduce TBI-induced oxidative stress, the number of damaged neurons, and the number of TUNEL-positive cells in the cortex of TBI models. Meanwhile, the levels of Beclin 1, LC3 II, and the number of LC3-positive cells in injured cortex were also increased following esketamine exposure. Western blotting and immunofluorescence assays showed that esketamine accelerated the nuclear translocation of TFEB, increased the p-AMPKα level and decreased the p-mTOR level. Similar results including nuclear translocation of TFEB, the increases of autophagy-related markers, and influences of AMPK/mTOR pathway were observed in H2O2-induced cortical neuronal cells; however, BML-275 (AMPK inhibitor) can reverse these effects of esketamine. Furthermore, TFEB silencing not only decreased the Nrf2 level in H2O2-induced cortical neuronal cells, but also alleviated the oxidative stress. Importantly, CO-IP confirmed the interaction between TFEB and Nrf2 in cortical neuronal cells. These findings suggested that esketamine exerts the neuroprotective effects of esketamine in TBI mice model via enhancing autophagy and alleviating oxidative stress; its mechanism involves AMPK/mTOR-dependent TFEB nuclear translocation-induced autophagy and TFEB/Nrf2-induced antioxidant system.
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Affiliation(s)
- Yanbin Tang
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Yufang Liu
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Huanzhu Zhou
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China; School of Anesthesiology, Xuzhou Medical University, Xuzhou 221004, Jiangsu, China
| | - Haibo Lu
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Yafei Zhang
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Jun Hua
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China
| | - Xingzhi Liao
- Department of Anesthesiology, 904th Hospital of The Joint Logistics Support Force of the PLA, Wuxi 214044, Jiangsu, China.
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6
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Floriano I, Silvinato A, Bernardo WM. The use of esketamine in the treatment of patients with oral antidepressant-resistant depression: systematic review and meta-analysis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023D696. [PMID: 37377288 DOI: 10.1590/1806-9282.2023d696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/19/2023] [Indexed: 06/29/2023]
Abstract
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field to standardize how to conduct, and to assist in the reasoning and decision-making of doctors. The information provided by this project must be critically evaluated by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical condition of each patient. Guideline conclusion: April 2023. Societies: Brazilian Medical Association.
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Affiliation(s)
- Idevaldo Floriano
- Cooperativa Baixa Mogiana, Evidence-Based Medicine - Mogi-Guaçu (SP), Brazil
| | - Antônio Silvinato
- Brazilian Medical Association, Evidence-Based Medicine - São Paulo (SP), Brazil
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Baryakova TH, Pogostin BH, Langer R, McHugh KJ. Overcoming barriers to patient adherence: the case for developing innovative drug delivery systems. Nat Rev Drug Discov 2023; 22:387-409. [PMID: 36973491 PMCID: PMC10041531 DOI: 10.1038/s41573-023-00670-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 03/29/2023]
Abstract
Poor medication adherence is a pervasive issue with considerable health and socioeconomic consequences. Although the underlying reasons are generally understood, traditional intervention strategies rooted in patient-centric education and empowerment have proved to be prohibitively complex and/or ineffective. Formulating a pharmaceutical in a drug delivery system (DDS) is a promising alternative that can directly mitigate many common impediments to adherence, including frequent dosing, adverse effects and a delayed onset of action. Existing DDSs have already positively influenced patient acceptability and improved rates of adherence across various disease and intervention types. The next generation of systems have the potential to instate an even more radical paradigm shift by, for example, permitting oral delivery of biomacromolecules, allowing for autonomous dose regulation and enabling several doses to be mimicked with a single administration. Their success, however, is contingent on their ability to address the problems that have made DDSs unsuccessful in the past.
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Affiliation(s)
| | | | - Robert Langer
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Kevin J McHugh
- Department of Bioengineering, Rice University, Houston, TX, USA.
- Department of Chemistry, Rice University, Houston, TX, USA.
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8
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Floriano I, Silvinato A, Bernardo WM. The use of esketamine in the treatment of patients with severe depression and suicidal ideation: systematic review and meta-analysis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023D694. [PMID: 37194806 DOI: 10.1590/1806-9282.2023d694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 03/28/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Idevaldo Floriano
- Cooperativa Baixa Mogiana, Evidence-Based Medicine - Mogi-Guaçu (SP), Brazil
| | - Antônio Silvinato
- Cooperativa Baixa Mogiana, Evidence-Based Medicine - Mogi-Guaçu (SP), Brazil
- Brazilian Medical Association, Evidence-Based Medicine - São Paulo (SP), Brazil
| | - Wanderley Marques Bernardo
- Brazilian Medical Association, Evidence-Based Medicine - São Paulo (SP), Brazil
- Universidade de São Paulo, Faculty of Medicine - São Paulo (SP), Brazil
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9
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Sobule R, Ithman M. Ketamine: Studies Show Benefit. MISSOURI MEDICINE 2023; 120:29-30. [PMID: 36860608 PMCID: PMC9970333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Robert Sobule
- Clinical Instructor of Psychiatry and Director of Psychiatric Advanced Practice Provider Fellowships at University of Missouri - Columbia School of Medicine Department of Psychiatry
| | - Muaid Ithman
- University of Missouri - Columbia School of Medicine, Department of Psychiatry Vice Chair; Associate Professor of Clinical Psychiatry; Medical Director for Interventional Psychiatry; and Associate Medical Director of Missouri, University Psychiatric Center
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10
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Liu Z, Wang X, Liu L, Xu H, Liu G, Wu G, Zhang H. Effect of oral esketamine on preoperative sedation and venipuncture analgesia in pediatric patients: a prospective randomized double-blind controlled clinical trial.. [DOI: 10.21203/rs.3.rs-2323639/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
Abstract
Abstract
Background
Anxiety and uncooperation are common among pediatric patients during the preoperative preparation, which requires adequate and appropriate analgesia and sedation.
Methods
We performed a prospective, randomized, double-blind, controlled clinical trial involving 1–6-year-old pediatric patients scheduled for elective tonsillectomy or adenoidectomy between December 2020 and May 2021. Patients were randomly assigned to control (group C), esketamine 1 mg.kg− 1 (group EK1), or esketamine 2 mg.kg− 1 (group EK2) group. Venipuncture analgesia, cooperation, and sedation, as well as satisfaction upon parent–child separation, cooperation, sedation, and adverse events, were compared among the three groups. Dynamic changes in the sedation score and vital signs were monitored.
Results
A total of 88 pediatric patients were analyzed, with 29, 29, and 30 patients in groups C, EK1, and EK2, respectively. Compared with group C, groups EK1 and EK2 both had better analgesia during venipuncture (P < 0.001). In addition, better cooperation and sedation was noticed in groups EK1 and EK2 during parent–child separation and venipuncture than in group C. Compared with the baseline, the mean respiratory rate had a significant decrease from 25.6 ± 0.3 to 24.6 ± 0.4 breaths/min at 30 min after the esketamine administration in group EK2, although it was still within normal limits (P = 0.030). There were no significant differences in adverse events among three groups.
Conclusions
Preoperative oral administration of 1 or 2 mg.kg− 1 esketamine in pediatric patients could achieve effective analgesia and sedation. Oral medication of 2 mg.kg− 1 esketamine had more pronounced effects.
Trial registration
: This clinical trial was registered at the Chinese Clinical Trial Registry (ChiCTR2000040739) on 08/12/2020.
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Martinotti G, Vita A, Fagiolini A, Maina G, Bertolino A, Dell'Osso B, Siracusano A, Clerici M, Bellomo A, Sani G, d'Andrea G, Chiaie RD, Conca A, Barlati S, Di Lorenzo G, De Fazio P, De Filippis S, Nicolò G, Rosso G, Valchera A, Nucifora D, Di Mauro S, Bassetti R, Martiadis V, Olivola M, Belletti S, Andriola I, Di Nicola M, Pettorruso M, McIntyre RS, di Giannantonio M. Real-world experience of esketamine use to manage treatment-resistant depression: A multicentric study on safety and effectiveness (REAL-ESK study). J Affect Disord 2022; 319:646-654. [PMID: 36167246 DOI: 10.1016/j.jad.2022.09.043] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/28/2022] [Accepted: 09/19/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Treatment-resistant Depression (TRD) represents a widespread disorder with significant direct and indirect healthcare costs. esketamine, the S-enantiomer of ketamine, has been recently approved for TRD, but real-world studies are needed to prove its efficacy in naturalistic settings. OBJECTIVES Evaluate the effectiveness and safety of esketamine nasal spray in a clinical sample of patients with TRD from several Italian mental health services. METHODS REAL-ESK study is an observational, retrospective and multicentric study comprising a total of 116 TRD patients treated with esketamine nasal spray. Anamnestic data and psychometric assessment (MADRS, HAMD-21, HAM-A) were collected from medical records at baseline (T0), one month (T1) and three month (T2) follow-ups. RESULTS A significant reduction of depressive symptoms was found at T1 and T2 compared to T0. A dramatic increase in clinical response (64.2 %) and remission rates (40.6 %) was detected at T2 compared to T1. No unexpected safety concerns were observed, side effects rates were comparable to those reported in RCTs. No differences in efficacy have been found among patients with and without psychiatric comorbidities. LIMITATIONS The open design of the study and the absence of a placebo or active comparator group are limitations. The study lacks an inter-rater reliability evaluation of the assessments among the different centres. Side effects evaluation did not involve any specific scale. CONCLUSIONS Our findings support the safety and tolerability of esketamine in a real-world TRD sample. The later response and the non-inferiority in effectiveness in patients with comorbidities represent novel and interesting findings.
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Affiliation(s)
- Giovanni Martinotti
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy; Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield AL10 9AB, UK
| | - Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Italy
| | - Andrea Fagiolini
- School of Medicine, Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Giuseppe Maina
- Department of Neurosciences "Rita Levi Montalcini", University of Torino, Turin, Italy
| | | | - Bernardo Dell'Osso
- Department of Biomedical and Clinical Sciences Luigi Sacco and Aldo Ravelli Center for Neurotechnology and Brain Therapeutic, University of Milan, Milano, Italy
| | - Alberto Siracusano
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Massimo Clerici
- Dipartimento di Medicina e Chirurgia, Università degli studi Milano Bicocca, Italy; Dipartimento di Salute Mentale e Dipendenze ASST Monza, Italy
| | - Antonello Bellomo
- Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Gabriele Sani
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giacomo d'Andrea
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy.
| | - Roberto Delle Chiaie
- Department of Neuroscience and Mental Health-Policlinico Umberto I Hospital, Sapienza University of Rome, 00161 Rome, Italy
| | - Andreas Conca
- Psychiatric Service of the Health District of Bozen, Bozen-Bolzano, Italy
| | - Stefano Barlati
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Department of Mental Health and Addiction Services, ASST Spedali Civili of Brescia, Italy
| | - Giorgio Di Lorenzo
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Pasquale De Fazio
- Psychiatry Unit, Department of Health Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | | | - Giuseppe Nicolò
- Department of Mental Health and Addiction, ASL Roma 5, Rome, Italy
| | - Gianluca Rosso
- Department of Neurosciences "Rita Levi Montalcini", University of Torino, Turin, Italy
| | | | | | | | - Roberta Bassetti
- SPDC Frosinone - ASL, Frosinone, Italy; Department of Mental Health and Addiction Services, Niguarda Hospital, Milan, Italy
| | | | - Miriam Olivola
- Department of Brain and Behavioural Science, University of Pavia, Italy
| | - Sandro Belletti
- Mental Heath Department, Azienda Unità Sanitaria Locale (AUSL) Umbria 2, Italy
| | | | - Marco Di Nicola
- Department of Neuroscience, Section of Psychiatry, Università Cattolica del Sacro Cuore, Rome, Italy; Department of Psychiatry, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Pettorruso
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, Poul Hansen Family Centre for Depression, University Health Network, Toronto, ON, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada; Canadian Rapid Treatment Center of Excellence, Mississauga, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Massimo di Giannantonio
- Department of Neurosciences, Imaging and Clinical Sciences, Università degli Studi G. D'Annunzio, Chieti, Italy
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12
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Shoib S, Kotra M, Javed S, Nguyen VS, Malathesh BC. Esketamine-A quick-acting novel antidepressant without the disadvantages of ketamine. Horm Mol Biol Clin Investig 2022; 43:505-511. [PMID: 35851448 DOI: 10.1515/hmbci-2021-0099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 05/23/2022] [Indexed: 12/24/2022]
Abstract
Esketamine, which is an S-enantiomer of ketamine, is better than conventional antidepressants and even better than R-ketamine. This article discusses the mechanism of action of Esketamine, how different it is from other antidepressants, its side effect profile, indications for use, various routes of administration and the review of existing literature on Esketamine.
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Affiliation(s)
- Sheikh Shoib
- Department of Psychiatry, Jawahar Lal Nehru Memorial Hospital, Srinagar, Kashmir, India
| | | | - Sana Javed
- Faculty of Medicine, Aleppo University, Aleppo, Syria
| | - Vinh-Son Nguyen
- Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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13
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Psiuk D, Nowak EM, Dycha N, Łopuszańska U, Kurzepa J, Samardakiewicz M. Esketamine and Psilocybin—The Comparison of Two Mind-Altering Agents in Depression Treatment: Systematic Review. Int J Mol Sci 2022; 23:ijms231911450. [PMID: 36232748 PMCID: PMC9570062 DOI: 10.3390/ijms231911450] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 11/16/2022] Open
Abstract
This publication discusses two compounds belonging to the psychoactive substances group which are studied in the context of depression treatment—psilocybin and esketamine. The former is a naturally occurring psychedelic. The latter was invented in the laboratory exactly 60 years ago. Although the substances were controversial in the past, recent studies indicate the potential of those substances as novel antidepressant agents. The PubMed/MEDLINE database was used to identify articles for systematic review, using the following search terms: (depression) AND (psilocybin) OR (ketamine). From 617 items, only 12 articles were obtained in the final analyses. Three articles were devoted to psilocybin in depression treatment and nine to esketamine. In most studies, esketamine showed a significant reduction in both depressive symptoms and suicidal ideation shortly after intake and after a month of treatment compared to baseline and to standard-of-care antidepressant agents. Psilocybin’s antidepressive effects occurred one day after intake and after 6–7 weeks of treatment and were maintained for up to 6 or 8 months of follow-up. One study indicated that psilocybin’s effects are comparable with and may be superior to escitalopram treatment. Both esketamine and psilocybin demonstrated rapid and long-term effects in reducing depression symptoms and, after overcoming some limitations, may be considered as novel antidepressant agents in future.
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Affiliation(s)
- Dominika Psiuk
- Students Scientific Association at the Chair and Department of Psychology, Medical University of Lublin, 20-059 Lublin, Poland
- Students Scientific Association at the Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
- Correspondence: or
| | - Emilia Magdalena Nowak
- Students Scientific Association at the Chair and Department of Psychology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Natalia Dycha
- Students Scientific Association at the Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
| | - Urszula Łopuszańska
- Chair and Department of Psychology, Medical University of Lublin, 20-059 Lublin, Poland
| | - Jacek Kurzepa
- Department of Medical Chemistry, Medical University of Lublin, 20-059 Lublin, Poland
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14
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Li Y, Wu ZY, Zheng WC, Wang JX, Yue-Xin, Song RX, Gao JG. Esketamine alleviates postoperative cognitive decline via stimulator of interferon genes/ TANK-binding kinase 1 signaling pathway in aged rats. Brain Res Bull 2022; 187:169-180. [PMID: 35839904 DOI: 10.1016/j.brainresbull.2022.07.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 06/17/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Postoperative cognitive decline (POCD) is a common complication after surgery and anesthesia among the elderly. Yet the potential mechanism of POCD remains ambiguous, with limited therapeutic measures currently available. Ketamine has been reported to attenuate POCD after cardiac surgery. Herein, we tried to determine the effect of esketamine (the S-enantiomer of ketamine) on POCD and the possible molecular mechanisms. METHODS We investigated the effects of esketamine (10 mg/kg) on POCD using an exploratory laparotomy model in aged SD rats (24 months). Open field, novel object recognition, and morris water maze tests were performed on day 30 post-surgery. 24 h or 30 d post-surgery, brain tissue from the hippocampus and ventromedial prefrontal cortex (vmPFC) was harvested and subjected to histopathology and molecular biology analysis. During the in vitro experiment, primary astrocytes from the hippocampus and vmPFC were exposed to lipopolysaccharide (LPS) to investigate the pathological changes in astrocytes during the process of POCD. RESULTS Our results indicated that exploratory laparotomy could induce significant cognitive and memory decline, accompanied by A2-type astrocytes phenotype loss and increased expression of neuron Aβ-42, astrocytes GABA, stimulator of interferon genes (STING) and TANK-binding kinase 1 (TBK1). In addition, LPS exposure significantly decreased the mitochondrial membrane potential and upregulated the level of pyroptosis-associated proteins, including cleaved caspase-1 and IL-18. Notably, treatment with esketamine reversed these abnormalities in vivo and vitro. However, ADU-S100, a special STING activator, suppressed the protective effects of esketamine to a certain extent. Finally, C-176, an antagonist of STING, further enhanced the protective effects of esketamine against POCD. CONCLUSIONS Findings of our study suggest that esketamine can alleviate surgery-induced POCD in rats via inhibition of the STING/TBK1 signaling pathway.
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Affiliation(s)
- Yan Li
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China; Department of Anesthesiology, Cangzhou Central Hospital, Cangzhou, Hebei, China
| | - Zhi-You Wu
- Department of Neurosurgery, Cangzhou Central Hospital, Graduate School of Hebei Medical University, Heibei, China
| | - Wei-Chao Zheng
- Department of Anesthesiology, Cangzhou Central Hospital, Graduate School of Hebei Medical University, Heibei, China
| | - Jie-Xia Wang
- Department of Anesthesiology, Cangzhou Central Hospital, Graduate School of Hebei Medical University, Heibei, China
| | - Yue-Xin
- Department of Anesthesiology, Cangzhou Central Hospital, Graduate School of Hebei Medical University, Heibei, China
| | - Rong-Xin Song
- Department of Anesthesiology, Cangzhou Central Hospital, Graduate School of Hebei Medical University, Heibei, China
| | - Jin-Gui Gao
- Department of Anesthesiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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15
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Yang S, Wang J, Li X, Wang T, Xu Z, Xu X, Zhou X, Chen G. Adverse Effects of Esketamine for the Treatment of Major Depression Disorder: Findings from Randomized Controlled Trials. Psychiatr Q 2022; 93:81-95. [PMID: 33411126 PMCID: PMC8993781 DOI: 10.1007/s11126-020-09871-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2020] [Indexed: 12/25/2022]
Abstract
Esketamine is a promising drug which can induce antidepressant effects in Major Depression Disorder (MDD). Several randomized controlled trials (RCTs) have been implemented to assess the efficacy and safety of esketamine for the treatment of MDD. Therefore, we carried out a meta-analysis to assess adverse effect profiles of esketamine for the treatment of MDD. We searched RCTs which were implemented from January 2010 to June 2020 by searching PubMed, Embase and Cochrane Library databases. Finally, four RCTs with 551 patients were included in our study. We pooled 551 patients from 4 RCTs. Compared with placebo, an increased risk of adverse effects was observed in our analysis. After using esketamine, the risk of nausea (RR = 2.34, 95% CI, 1.04 to 5.25, P = 0.04), dissociation (RR = 4.54, 95% CI, 2.36 to 8.73, P < 0.00001), dizziness (RR = 3.00, 95% CI, 1.80 to 5.00, P < 0.0001), vertigo (RR = 7.47, 95% CI, 2.55 to 21.86, P = 0.0002), hypoesthesia (RR = 5.68, 95% CI, 2.06 to 15.63, P = 0.0008), sedation (RR = 3.96, 95% CI, 1.29 to 12.15, P = 0.02) and paresthesia(RR = 3.05, 95% CI, 1.07 to 8.65, P = 0.04)were significantly increased compared with placebo. Our synthesized data analysis revealed drug specific risk profiles. The most frequent adverse effects under treatment with esketamine were nausea, dissociation, dizziness, vertigo, hypoesthesia,sedation and paresthesia.
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Affiliation(s)
- Siyuan Yang
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Jiahe Wang
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiang Li
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Tianyi Wang
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Zhongmou Xu
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Xiang Xu
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China.
| | - Xinmin Zhou
- Department of Clinical Medicine, The Affiliated Jiangyin Hospital, School of Medicine, Southeast University, Jiangyin, Jiangsu Province, China.
| | - Gang Chen
- Department of Clinical Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
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16
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Smith-Apeldoorn SY, Veraart JKE, Ruhé HG, Aan Het Rot M, Kamphuis J, de Boer MK, Schoevers RA. Repeated, low-dose oral esketamine in patients with treatment-resistant depression: pilot study. BJPsych Open 2021; 8:e4. [PMID: 34865676 PMCID: PMC8693908 DOI: 10.1192/bjo.2021.1059] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Intravenous infusion of ketamine can produce rapid and large symptom reduction in patients with treatment-resistant depression (TRD) but presents major obstacles to clinical applicability, especially in community settings. Oral esketamine may be a promising addition to our TRD treatment armamentarium. AIMS To explore the safety, tolerability and potential clinical effectiveness of a 3-week treatment with repeated, low-dose oral esketamine. METHOD Seven patients with chronic and severe TRD received 1.25 mg/kg generic oral esketamine daily, over 21 consecutive days. Scores on the Systematic Assessment for Treatment Emergent Events (SAFTEE), Community Assessment of Psychic Experiences (CAPE), Clinician Administered Dissociative States Scale (CADSS) and Hamilton Rating Scale for Depression (HRSD) instruments, as well as blood pressure and heart rate, were repeatedly assessed. RESULTS Treatment with oral esketamine was well-tolerated. No serious side-effects occurred, and none of the participants discontinued treatment prematurely. Psychotomimetic effects were the most frequently reported adverse events. Mean HDRS score decreased by 16.5%, from 23.6 to 19.7. Three participants showed reductions in HDRS scores above the minimum clinically important difference (eight-point change), of whom two showed partial response. No participants showed full response or remission. CONCLUSIONS These results strengthen the idea that oral esketamine is a safe and well-tolerated treatment for patients with chronic and severe TRD, but therapeutic effects were modest. Results were used to design a randomised controlled trial that is currently in progress.
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Affiliation(s)
- Sanne Y Smith-Apeldoorn
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Jolien K E Veraart
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, The Netherlands; and Department of Mood Disorders, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Netherlands
| | - Henricus G Ruhé
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, The Netherlands; and Department of Psychiatry, Radboud University Medical Center, The Netherlands
| | | | - Jeanine Kamphuis
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Marrit K de Boer
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University of Groningen, University Medical Center Groningen, The Netherlands
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17
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Caldiroli A, Capuzzi E, Tagliabue I, Capellazzi M, Marcatili M, Mucci F, Colmegna F, Clerici M, Buoli M, Dakanalis A. Augmentative Pharmacological Strategies in Treatment-Resistant Major Depression: A Comprehensive Review. Int J Mol Sci 2021; 22:ijms222313070. [PMID: 34884874 PMCID: PMC8658307 DOI: 10.3390/ijms222313070] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/29/2021] [Accepted: 12/01/2021] [Indexed: 01/09/2023] Open
Abstract
Treatment resistant depression (TRD) is associated with poor outcomes, but a consensus is lacking in the literature regarding which compound represents the best pharmacological augmentation strategy to antidepressants (AD). In the present review, we identify the available literature regarding the pharmacological augmentation to AD in TRD. Research in the main psychiatric databases was performed (PubMed, ISI Web of Knowledge, PsychInfo). Only original articles in English with the main topic being pharmacological augmentation in TRD and presenting a precise definition of TRD were included. Aripiprazole and lithium were the most investigated molecules, and aripiprazole presented the strongest evidence of efficacy. Moreover, olanzapine, quetiapine, cariprazine, risperidone, and ziprasidone showed positive results but to a lesser extent. Brexpiprazole and intranasal esketamine need further study in real-world practice. Intravenous ketamine presented an evincible AD effect in the short-term. The efficacy of adjunctive ADs, antiepileptic drugs, psychostimulants, pramipexole, ropinirole, acetyl-salicylic acid, metyrapone, reserpine, testosterone, T3/T4, naltrexone, SAMe, and zinc cannot be precisely estimated in light of the limited available data. Studies on lamotrigine and pindolol reported negative results. According to our results, aripiprazole and lithium may be considered by clinicians as potential effective augmentative strategies in TRD, although the data regarding lithium are somewhat controversial. Reliable conclusions about the other molecules cannot be drawn. Further controlled comparative studies, standardized in terms of design, doses, and duration of the augmentative treatments, are needed to formulate definitive conclusions.
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Affiliation(s)
- Alice Caldiroli
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
- Correspondence: ; Tel.: +39-3495009941
| | - Enrico Capuzzi
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
| | - Ilaria Tagliabue
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
| | - Martina Capellazzi
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
| | - Matteo Marcatili
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
| | - Francesco Mucci
- Department of Medicine and Surgery, University of Milan, 20122 Milan, Italy;
| | - Fabrizia Colmegna
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
| | - Massimo Clerici
- Psychiatric Department, Azienda Socio Sanitaria Territoriale Monza, 20900 Monza, Italy; (E.C.); (M.M.); (F.C.); (M.C.)
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
| | - Massimiliano Buoli
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy;
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Antonios Dakanalis
- Department of Medicine and Surgery, University of Milano Bicocca, 20900 Monza, Italy; (I.T.); (M.C.); (A.D.)
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18
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Derakhshanian S, Zhou M, Rath A, Barlow R, Bertrand S, DeGraw C, Lee C, Hasoon J, Kaye AD. Role of Ketamine in the Treatment of Psychiatric Disorders. Health Psychol Res 2021; 9:25091. [PMID: 35106397 PMCID: PMC8801551 DOI: 10.52965/001c.25091] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/17/2021] [Indexed: 09/02/2023] Open
Abstract
PURPOSE OF REVIEW This is a comprehensive review of the literature regarding the use of ketamine as a treatment for treatment-resistant depression (TRD). It covers the epidemiology, risk factors, pathophysiology, and current treatment modalities regarding Major Depressive Disorder (MDD) and TRD. It provides background on the mechanism of action of ketamine, its history, current approved and off-label indications in the field of psychiatry, and then provides an overview of the existing evidence for the use of ketamine in the treatment of TRD. RECENT FINDINGS MDD is a mental illness that puts an enormous strain on the affected and a high socio-economic burden on society. The illness is complex and combines genetic, pathophysiologic, and environmental factors that combine to negatively affect neurotransmitter balance in the brain. Additional evidence suggests dysregulation of the hypothalamic-pituitary (HPA) axis, brain-derived neurotrophic factor (BDNF), vitamin D levels, and involvement of pro-inflammatory markers. Core symptoms include depressed mood or anhedonia, combined with neurovegetative symptoms such as sleep impairment, changes in appetite, feelings of worthlessness and guilt, and psychomotor retardation. Current first-line treatment options are antidepressants of the selective serotonin reuptake inhibitor (SSRI) and serotonin-norepinephrine reuptake inhibitor (SNRI) class. Failure to respond to two adequate trials of treatment meets the criteria for TRD. Esketamine (Spravato) is an NMDA-receptor antagonist with additional AMPA-receptor agonist properties, which the FDA approved in 2019 to treat adult TRD in conjunction with an oral antidepressant. It can be administered intranasally, providing a rapid response and proven effective and safe. Additional research suggests that oral ketamine might be effective for PTSD and anxiety disorders. Intravenous administration of ketamine has also shown benefits for acute suicidal ideation and depression and substance use to reduce relapse rates. SUMMARY TRD is associated with huge costs on individual and societal levels. Underlying disease processes are multifactorial and not well understood. Adjunctive therapies for TRD with proven benefits exist, but acutely depressed and suicidal patients often require prolonged inpatient stabilization. Intranasal esketamine is a new FDA-approved alternative with rapid benefit for TRD, which has also shown a rapid reduction in suicidal ideation while maintaining a favorable side-effect profile. Additional potential off-label uses for ketamine in psychiatric disorders have been studied, including PTSD, anxiety disorders, bipolar depression, and substance use disorders.
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Affiliation(s)
| | - Maxine Zhou
- Department of Psychiatry, Louisiana State University Shreveport, LA
| | - Alexander Rath
- Department of Psychiatry, Louisiana State University Shreveport, LA
| | - Rachel Barlow
- Louisiana State University Health Sciences Center Shreveport School of Medicine, LA
| | - Sarah Bertrand
- Louisiana State University Health Sciences Center Shreveport School of Medicine, LA
| | - Caroline DeGraw
- Louisiana State University Health Sciences Center Shreveport School of Medicine, LA
| | - Christopher Lee
- Department of Internal Medicine, Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, AZ
| | - Jamal Hasoon
- Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Shreveport, LA
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Carboni E, Carta AR, Carboni E, Novelli A. Repurposing Ketamine in Depression and Related Disorders: Can This Enigmatic Drug Achieve Success? Front Neurosci 2021; 15:657714. [PMID: 33994933 PMCID: PMC8120160 DOI: 10.3389/fnins.2021.657714] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 03/31/2021] [Indexed: 12/27/2022] Open
Abstract
Repurposing ketamine in the therapy of depression could well represent a breakthrough in understanding the etiology of depression. Ketamine was originally used as an anesthetic drug and later its use was extended to other therapeutic applications such as analgesia and the treatment of addiction. At the same time, the abuse of ketamine as a recreational drug has generated a concern for its psychotropic and potential long-term effects; nevertheless, its use as a fast acting antidepressant in treatment-resistant patients has boosted the interest in the mechanism of action both in psychiatry and in the wider area of neuroscience. This article provides a comprehensive overview of the actions of ketamine and intends to cover: (i) the evaluation of its clinical use in the treatment of depression and suicidal behavior; (ii) the potential use of ketamine in pediatrics; (iii) a description of its mechanism of action; (iv) the involvement of specific brain areas in producing antidepressant effects; (v) the potential interaction of ketamine with the hypothalamic-pituitary-adrenal axis; (vi) the effect of ketamine on neuronal transmission in the bed nucleus of stria terminalis and on its output; (vii) the evaluation of any gender-dependent effects of ketamine; (viii) the interaction of ketamine with the inflammatory processes involved in depression; (ix) the evaluation of the effects observed with single or repeated administration; (x) a description of any adverse or cognitive effects and its abuse potential. Finally, this review attempts to assess whether ketamine's use in depression can improve our knowledge of the etiopathology of depression and whether its therapeutic effect can be considered an actual cure for depression rather than a therapy merely aimed to control the symptoms of depression.
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Affiliation(s)
- Ezio Carboni
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Anna R. Carta
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Elena Carboni
- Unit of Paediatrics, ASST Cremona Maggiore Hospital, Cremona, Italy
| | - Antonello Novelli
- Department of Psychology and University Institute of Biotechnology of Asturias, University of Oviedo, Oviedo, Spain
- Sanitary Institute of the Princedom of Asturias, Oviedo, Spain
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20
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Comparative efficacy of racemic ketamine and esketamine for depression: A systematic review and meta-analysis. J Affect Disord 2021; 278:542-555. [PMID: 33022440 PMCID: PMC7704936 DOI: 10.1016/j.jad.2020.09.071] [Citation(s) in RCA: 174] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Ketamine appears to have a therapeutic role in certain mental disorders, most notably depression. However, the comparative performance of different formulations of ketamine is less clear. OBJECTIVES This study aimed to assess the comparative efficacy and tolerability of racemic and esketamine for the treatment of unipolar and bipolar major depression. DESIGN Systematic review and meta-analysis. DATA SOURCES We searched PubMed, MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Clinical Trials, and the Cochrane Database of Systematic Reviews for relevant studies published since database inception and December 17, 2019. STUDY ELIGIBILITY CRITERIA We considered randomized controlled trials examining racemic or esketamine for the treatment of unipolar or bipolar major depression. OUTCOMES Primary outcomes were response and remission from depression, change in depression severity, suicidality, retention in treatment, drop-outs, and drop-outs due to adverse events. ANALYSIS Evidence from randomized controlled trials was synthesized as rate ratios (RRs) for treatment response, disorder remission, adverse events, and withdrawals and as standardized mean differences (SMDs) for change in symptoms, via random-effects meta-analyses. FINDINGS 24 trials representing 1877 participants were pooled. Racemic ketamine relative to esketamine demonstrated greater overall response (RR = 3.01 vs. RR = 1.38) and remission rates (RR = 3.70 vs. RR = 1.47), as well as lower dropouts (RR = 0.76 vs. RR = 1.37). CONCLUSIONS Intravenous ketamine appears to be more efficacious than intranasal esketamine for the treatment of depression.
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Smith-Apeldoorn SY, Veraart JKE, Kamphuis J, van Asselt ADI, Touw DJ, aan het Rot M, Schoevers RA. Correction to: Oral esketamine for treatment-resistant depression: rationale and design of a randomized controlled trial. BMC Psychiatry 2020; 20:9. [PMID: 31914973 PMCID: PMC6947821 DOI: 10.1186/s12888-019-2398-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
After publication of our article [1] we were notified that Figure 1 was wrongly presented.
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Affiliation(s)
- Sanne Y. Smith-Apeldoorn
- 0000 0000 9558 4598grid.4494.dDepartment of Psychiatry, University of Groningen, University Medical Center Groningen, PO box 30.0001, 9700 RB Groningen, The Netherlands
| | - Jolien K. E. Veraart
- 0000 0000 9558 4598grid.4494.dDepartment of Psychiatry, University of Groningen, University Medical Center Groningen, PO box 30.0001, 9700 RB Groningen, The Netherlands ,grid.491389.eDepartment of Psychiatry, PsyQ Haaglanden, Parnassia Psychiatric Institute, The Hague, The Netherlands
| | - Jeanine Kamphuis
- 0000 0000 9558 4598grid.4494.dDepartment of Psychiatry, University of Groningen, University Medical Center Groningen, PO box 30.0001, 9700 RB Groningen, The Netherlands
| | - Antoinette D. I. van Asselt
- 0000 0000 9558 4598grid.4494.dDepartment of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Daan J. Touw
- 0000 0000 9558 4598grid.4494.dDepartment of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marije aan het Rot
- 0000 0004 0407 1981grid.4830.fDepartment of Psychology, University of Groningen, Groningen, The Netherlands
| | - Robert A. Schoevers
- 0000 0000 9558 4598grid.4494.dDepartment of Psychiatry, University of Groningen, University Medical Center Groningen, PO box 30.0001, 9700 RB Groningen, The Netherlands
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