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Marzoughi S, Ripsman D, Ong M. Therapeutic effects of 7- to 14-day subanesthetic ketamine infusions for chronic pain on standardized psychiatric measures. Pain Manag 2023; 13:529-538. [PMID: 37656045 DOI: 10.2217/pmt-2023-0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
Abstract
Background: We have previously shown that subanesthetic ketamine infusions effectively reduce refractory pain. However, the effects of ketamine infusions on comorbid conditions of depression and anxiety have not been explored in this patient population. Methods: We investigated the effects of ketamine on mood and anxiety in patients with refractory chronic pain treated with 7-14 days of subanesthetic continuous intravenous ketamine infusions, using well-validated clinical scales. Results: There was a significant 52% reduction in pain severity and 33% reduction in pain interference scores following ketamine treatment. Ketamine treatment also reduced scores on the depression module of the Patient Health Questionnaire (PHQ-9) by 28% and scores on the Generalised Anxiety and Depression Assessment (GAD-7) by 36%. Conclusion: Multiday subanesthetic ketamine infusions effectively reduce pain, anxiety and depression in patients with complex chronic pain.
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Affiliation(s)
- Sina Marzoughi
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, V6T 2B5, Canada
| | - David Ripsman
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, V6T 2B5, Canada
| | - May Ong
- Department of Medicine, Division of Internal Medicine, University of British Columbia, Vancouver, BC, V6T 2B5, Canada
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2
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Muacevic A, Adler JR. Effectiveness of Low-Dose Ketamine Infusion in Opioid Refractory Cancer Pain: A Case Report. Cureus 2022; 14:e31662. [PMID: 36545179 PMCID: PMC9762523 DOI: 10.7759/cureus.31662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 11/21/2022] Open
Abstract
Most patients with advanced cancer experience debilitating pain, which significantly affects their quality of life and has both physical and psychological implications. Opioids have been the mainstay of treatment for chronic cancer pain, but some people develop serious adverse effects or may become refractory to opioid use. There is always a need and search for alternative non-opioid analgesics with an acceptable safety profile, and one such drug is ketamine. In this era of evolving analgesic therapeutics, ketamine has been noted to have favourable results. Ketamine, a phencyclidine analogue, is an N-methyl-D-aspartate antagonist (NMDA), and it has been shown to have an analgesic effect at sub-anaesthetic doses by blocking NMDA-induced pain sensitization and enhancing opioid receptor sensitization. This is a case report of a 46-year-old Indian female with recurrent metastatic adenocarcinoma endometrium (International Federation of Obstetrics and Gynecology (FIGO) Grade II) involving the vaginal vault, rectum, and adrenal glands, along with para-rectal, bilateral iliac, and retroperitoneal nodal metastases, in which ketamine infusion was used successfully to alleviate the pain that was initially not controlled with an incremental dose of opioids. The patient presented with progressive pain in the peri-anal region, rated 8/10 on the Numerical Pain Rating Scale (NRS), following which she was treated with escalating doses of intravenous (IV) fentanyl, but with little to no relief. In view of the patient's opioid-resistant pain, she was started on a low-dose ketamine IV infusion (50 mg in 50 ml of 0.9% NS) as "burst therapy," at infusion rates of 0.02 mg/kg/hr-0.08 mg/kg/hr, with adequate pain relief occurring at 0.08 mg/kg/hr. Literature suggests weight-based dosing of ketamine ranging from 0.06 mg/kg/hr to 0.8 mg/kg/hr was previously used to achieve satisfactory results. In this patient, even lower doses were effectively used to achieve optimum long-term analgesia, cause an upliftment in the patient's overall mood and quality of life, and cause a significant reduction in opioid usage. However, further research is required to assess the efficacy of ketamine at such doses and its effect on opioid consumption. This case report will promote further study regarding optimum IV ketamine dosing and administration in the management of opioid-refractory pain in cancer patients, especially in the Indian population.
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Awdishu L, Singh RF, Saunders I, Yam FK, Hirsch JD, Lorentz S, Atayee RS, Ma JD, Tsunoda SM, Namba J, Mnatzaganian CL, Painter NA, Watanabe JH, Lee KC, Daniels CD, Morello CM. Advancing Pharmacist Collaborative Care within Academic Health Systems. PHARMACY 2019; 7:pharmacy7040142. [PMID: 31614555 PMCID: PMC6958419 DOI: 10.3390/pharmacy7040142] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 09/10/2019] [Accepted: 10/05/2019] [Indexed: 11/16/2022] Open
Abstract
Introduction: The scope of pharmacy practice has evolved over the last few decades to focus on the optimization of medication therapy. Despite this positive impact, the lack of reimbursement remains a significant barrier to the implementation of innovative pharmacist practice models. Summary: We describe the successful development, implementation and outcomes of three types of pharmacist collaborative care models: (1) a pharmacist with physician oversight, (2) pharmacist–interprofessional teams and (3) physician–pharmacist teams. The outcome measurement of these pharmacist care models varied from the design phase to patient volume measurement and to comprehensive quality dashboards. All of these practice models have been successfully funded by affiliated health systems or grants. Conclusions: The expansion of pharmacist services delivered by clinical faculty has several benefits to affiliated health systems: (1) significant improvements in patient care quality, (2) access to experts in specialty areas, and (3) the dissemination of outcomes with national and international recognition, increasing the visibility of the health system.
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Affiliation(s)
- Linda Awdishu
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Renu F Singh
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Ila Saunders
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Felix K Yam
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- Veterans Affairs San Diego Healthcare System, La Jolla, CA 92093, USA.
| | - Jan D Hirsch
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- Irvine School of Pharmacy and Pharmaceutical Sciences, University of California, Irvine, CA 92697, USA.
| | - Sarah Lorentz
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
| | - Rabia S Atayee
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Joseph D Ma
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Shirley M Tsunoda
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Jennifer Namba
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Christina L Mnatzaganian
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Nathan A Painter
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Jonathan H Watanabe
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
| | - Kelly C Lee
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Charles D Daniels
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- San Diego Health System, University of California, La Jolla, CA 92093, USA.
| | - Candis M Morello
- San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California, La Jolla, CA 92093, USA.
- Veterans Affairs San Diego Healthcare System, La Jolla, CA 92093, USA.
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Abstract
OBJECTIVE In the context of the current opioid epidemic, there has been a renewed interest in the use of ketamine as an analgesic agent. METHODS We reviewed ketamine analgesia. RESULTS Ketamine is well-known as an antagonist for N-methyl-D-aspartate receptors. In addition, it can regulate the function of opioid receptors and sodium channels. Ketamine also increases signaling through α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptors. These myriad of molecular and cellular mechanisms are responsible for a number of pharmacological functions including pain relief and mood regulation. Clinically, a number of studies have investigated the role of ketamine in the setting of acute and chronic pain, and there is evidence that ketamine can provide analgesia in a variety of pain syndromes. DISCUSSION In this review, we examined basic mechanisms of ketamine and its current clinical use and potential novel use in pain management.
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Moazam C, Hirst J, Mesarwi P, Atayee RS. Ketamine: When Delirium and Desperation Call for a Hero. J Pain Palliat Care Pharmacother 2019; 33:120-124. [DOI: 10.1080/15360288.2019.1686099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Medioni J, Pickering G, Delorme C, Lansaman T, Lanteri-Minet M, Legras A, Navez M, Prudhomme M, Serrie A, Viel É, Perrot S. [Drug management of cancer-related peripheral neuropathic pain: A systematic review of the literature]. Bull Cancer 2019; 106:784-795. [PMID: 31202559 DOI: 10.1016/j.bulcan.2019.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 04/07/2019] [Accepted: 04/26/2019] [Indexed: 12/23/2022]
Abstract
The objective of the present systematic literature review was to provide an update on medical treatment of neuropathic pain in cancer patients. The number of cancer patients is steadily increasing. Pain is frequent in cancer patients. Few studies have focused on medical treatment of pain, and especially of neuropathic pain, in current or former cancer patients. The present systematic review of all studies published between December 2012 and August 2018 was intended to estimate the scale of this lack. In all, 27 articles were identified on a systematic PubMed search and from the authors' personal knowledge, confirming that scant data have been published. The heterogeneity of cancer patients, of cancer, and of pain go some way toward explaining this scarcity. Guidelines, founded mainly on results from non-cancer patients, recommend tricyclic antidepressants and antiepileptic drugs; local treatments have the advantage of good systemic tolerance. Larger-scale studies taking account of the etiology of neuropathic pain, its characteristics (strictly neuropathic or mixed) and patient characteristics (awaiting treatment, under treatment, recent or non-recent survivor, or in terminal phase) along the care pathway are needed to improve knowledge. The results of the present literature analysis can help future research.
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Affiliation(s)
- Jacques Medioni
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital européen Georges-Pompidou, faculté de médecine Paris Descartes, centre d'essais précoces en cancérologie (CEPEC), service de cancérologie médicale, 75015 Paris, France.
| | - Gisèle Pickering
- CHU de Clermont-Ferrand, université Clermont-Auvergne, centre de pharmacologie clinique, CIC Inserm 1405, 60003 Clermont-Ferrand, France
| | - Claire Delorme
- Centre hospitalier de Bayeux, centre d'évaluation et traitement de la douleur (CETD) et réseau régional douleur, 14400 Bayeux, France
| | - Thibaud Lansaman
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, service de médecine physique et de réadaptation, 92380 Paris, France
| | - Michel Lanteri-Minet
- CHU de Nice, fédération hospitalo-universitaire InovPain, université Côte-d'Azur, département d'évaluation et traitement de la douleur, 06000 Nice, France; Université d'Auvergne, Inserm/UdA, U1107, Neuro-Dol, 60003 Clermont-Ferrand, France
| | - Antoine Legras
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital européen Georges-Pompidou, 75015 Paris, France
| | - Malou Navez
- CHU de Saint-Étienne, centre d'évaluation et traitement de la douleur (CETD), 41000 Saint-Priest-en-Jarez, France
| | - Michel Prudhomme
- CHU de Nîmes, département de chirurgie viscérale, 30029 Nîmes, France
| | - Alain Serrie
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Lariboisière-Fernand-Widal, universités Paris Descartes-Paris Diderot, service de médecine de la douleur et de médecine palliative, Inserm UMR-S 1144, 75010 Paris, France
| | - Éric Viel
- CHU de Nîmes, faculté de médecine Montpellier-Nîmes, centre d'évaluation et de traitement de la douleur, 30029 Nîmes, France
| | - Serge Perrot
- Assistance publique-Hôpitaux de Paris (AP-HP), hôpital Cochin, université Paris Descartes, centre d'évaluation et de traitement de la douleur, Inserm U987, 75014 Paris, France
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Rascón-Martínez D, Carrillo-Torres O, Ramos-Nataren R, Rendón-Jaramillo L. Advantages of ketamine as a perioperative analgesic. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2018. [DOI: 10.1016/j.hgmx.2016.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Hakim RC, Edmonds KP, Atayee RS. Case Report: Utility of Ketamine, Lidocaine, and Mexiletine as Nonopioid Adjuvants in Complex Cancer-Associated Pain. J Pain Palliat Care Pharmacother 2018; 32:15-19. [PMID: 29737933 DOI: 10.1080/15360288.2018.1463345] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Ketamine, lidocaine, and mexiletine are potential nonopioid adjuvant medications for the use of refractory cancer-related pain, particularly when opioids are demonstrating limited objective benefit. This is a case report of a single patient admitted to a large academic medical center in the United States. The patient is a 43-year-old woman with a history of Crohn's disease complicated by rectal squamous cell carcinoma and complex, progressive, and intractable pelvic and rectal pain. Over the course of hospitalization, her pain demonstrated limited opioid responsiveness despite marked fluctuations of her oral morphine equivalent doses. She also demonstrates variable responsiveness to ketamine. Lidocaine continuous infusion ultimately proves beneficial, and she is discharged after conversion to oral mexiletine. An overview of the hospital system's protocols for ketamine and lidocaine continuous infusions for pain and considerations for transitioning to mexiletine from lidocaine infusion are included.
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Li L, Vlisides PE. Ketamine: 50 Years of Modulating the Mind. Front Hum Neurosci 2016; 10:612. [PMID: 27965560 PMCID: PMC5126726 DOI: 10.3389/fnhum.2016.00612] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 11/15/2016] [Indexed: 01/14/2023] Open
Abstract
Ketamine was introduced into clinical practice in the 1960s and continues to be both clinically useful and scientifically fascinating. With considerably diverse molecular targets and neurophysiological properties, ketamine’s effects on the central nervous system remain incompletely understood. Investigators have leveraged the unique characteristics of ketamine to explore the invariant, fundamental mechanisms of anesthetic action. Emerging evidence indicates that ketamine-mediated anesthesia may occur via disruption of corticocortical information transfer in a frontal-to-parietal (“top down”) distribution. This proposed mechanism of general anesthesia has since been demonstrated with anesthetics in other pharmacological classes as well. Ketamine remains invaluable to the fields of anesthesiology and critical care medicine, in large part due to its ability to maintain cardiorespiratory stability while providing effective sedation and analgesia. Furthermore, there may be an emerging role for ketamine in treatment of refractory depression and Post-Traumatic Stress Disorder. In this article, we review the history of ketamine, its pharmacology, putative mechanisms of action and current clinical applications.
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Affiliation(s)
- Linda Li
- Department of Internal Medicine, St. Joseph Mercy Hospital Ann Arbor, MI, USA
| | - Phillip E Vlisides
- Department of Anesthesiology, University of Michigan Medical School Ann Arbor, MI, USA
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Meymandi MS, Keyhanfar F, Yazdanpanah O, Heravi G. The Role of NMDARs Ligands on Antinociceptive Effects of Pregabalin in the Tail Flick Test. Anesth Pain Med 2015; 5:e28968. [PMID: 26587404 PMCID: PMC4644310 DOI: 10.5812/aapm.28968] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 06/10/2015] [Accepted: 07/20/2015] [Indexed: 12/16/2022] Open
Abstract
Background: Pregabalin as a new anticonvulsant has been used in different pain treatments. Objectives: The aim of this study was to investigate the role of N-methyl-D-aspartate (NMDA) ligands in antinociceptive effect of pregabalin in mice using tail flick. Materials and Methods: NMDA (15 and 30 mg/kg) as an agonist or MK801 (0.02 and 0.05 mg/kg) as an antagonist were injected intraperitoneally either alone or 15 minutes before antinociceptive dose of pregabalin (100 mg/kg). Then the latency times and %MPE were measured in the tail flick assay during 75 minutes. Results: NMDA and MK801 had no effects alone. NMDA pretreatment significantly decreased the latency times of pregabalin till 75th minutes. In NMDA pretreated groups, %MPE30 unlike %MPE75 decreased significantly compared to those of pregabalin. MK801 delayed the latency times in pretreated groups, but %MPE30 and %MPE75 did not change significantly compared to pregabalin alone. Conclusions: Our findings support the role of NMDARs in pregabalin antinociception, because the NMDAR agonist, unlike the antagonist, decreased the antinociceptive effect of pregabalin, even if tail flick is not an adequate pain assessment method in this regard.
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Affiliation(s)
- Manzumeh-Shamsi Meymandi
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Fariborz Keyhanfar
- Pharmacology Department, Iran University of Medical Sciences, Tehran, Iran
- Corresponding author: Fariborz Keyhanfar, Pharmacology Department, Iran University of Medical Sciences, Tehran, Iran. Tel: +98-2188058696, Fax: +98-2188052978, E-mail:
| | - Omid Yazdanpanah
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Gioia Heravi
- Neuroscience Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
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