The Science Behind Ketamine Treatment

Medical Applications of Ketamine

Ketamine (ketamine hydrochloride) has been approved for use in general anesthesia either alone or in combination with other medications. It is a superb drug for use in short-term medical procedures that do not require skeletal muscle relaxation, and it has approval for the induction of general anesthesia as a pre-anesthetic to other general anesthetic agents.

It also has indications for supplementing low-potency agents such as nitrous oxide. Ketamine is used for short-term procedural sedation, rapid sequence intubation, and is very useful in the emergency department setting for these conditions. It is the medication of choice for patients with bronchospasm because of its bronchodilatory properties. It can be utilized for procedures requiring short-term sedation/anesthesia, such as the reduction of fractures and dislocations, as well as in wound repair in uncooperative patients, especially children. It can be safely used in a wide age range, beginning at three months. Because children metabolize ketamine faster than adults, higher dosing is required than in the adult population. Elderly patients, on the other hand, need lower dosing since they are slow metabolizers of this agent.

Ketamine Works Quickly

Ketamine, has shown considerable promise as a fast-acting antidepressant in patients with Treatment Resistant Depression, alleviating depressive symptoms and reversing suicidal ideation within hours following a single, low-dose (0.5mg/kg) intravenous (i.v.) infusion, and having effects lasting up to one week, on average (Ballard et al., 2014Berman et al., 2000Phelps et al., 2009Zarate et al., 2006).

Ketamine is Safe

Ketamine generally maintains normal pharyngeal and laryngeal reflexes and, therefore, permits spontaneous respiration. It slightly enhances or maintains normal skeletal muscle tone and is associated with cardiovascular and respiratory stimulation. Blood pressure elevation of 10-15mm Hg is a possible side effect.

Ketamine is Affordable

50mg of ketamine for IM injection costs $1.10

The major cost associated with initiating treatment is due to the necessity of administering it in a medical setting with cardiac monitoring for 60-90minutes.

Ketamine lozenges for home treatment are $50/month.

Unique Mechanism of Action

At higher doses, Ketamine hydrochloride is a nonbarbiturate dissociative anesthetic. This dissociation is a complete and temporary disconnection between a person’s thoughts, memories, feelings, actions and sense of who he or she is.

When used for pain management, sub-dissociative dosing, otherwise known as low dose ketamine (LDK) is used, either alone or as an adjunct to other medications for pain relief. It is safe and effective to use in combination with injectable nonsteroidal pain medications as well as opioids. It has gained greater acceptance as concern has grown regarding opioid use. 

Ketamine’s effects in chronic pain, and as an antidepressant, far outlast the actual drug levels, and are probably mediated by a secondary increase in structural synaptic connectivity that is mediated by a neuronal response to the ketamine-induced hyper-glutamatergic state.” (Sleigh 2014).

Another reason ketamine has researchers excited is that it works differently than existing antidepressants. Rather than affecting one of the “monoamine” neurotransmitters (serotonin, norepinephrine and dopamine), as standard antidepressants do, it acts on glutamate, the most common chemical messenger in the brain. Glutamate plays an important role in the changes synapses undergo in response to experiences that underlie learning and memory. That is why researchers suspected such “neuroplasticity” would lie at the heart of ketamine’s antidepressant effects. Scientific American April 12, 2019

Additional Treatment Information

Some patients have dissociation with treatment accompanied by insightful thoughts that have life altering positive effects.  This is a side effect of ketamine.  It is not the therapeutic mechanism of action or a goal of treatment.

  • Treatment resistant depression
  • Medication assisted counselling (CBT) for anxiety
  • Addiction cravings, only med that helps with alcohol, benzos, cocaine, and marijuana
  • Ketamine treats suicidality quickly

2 IM treatments weekly for 3 weeks to assess efficacy

Ketamine administration every 2–3 days over a two-week period, maintains the antidepressant response, increases the percentage of patients responding to ketamine, and lengthens the duration of antidepressant response after cessation of treatment (aan het Rot et al., 2010Murrough et al., 2013Shiroma et al., 2014a).

When administered IM, the onset of action is approximately 4 minutes with a duration of action from 15 to 30 minutes. Ketamine Steven B. Rosenbaum; Vikas Gupta; Jorge L. Palacios.https://www.ncbi.nlm.nih.gov/

Sublingual Lozenges every 3-7 days for maintenance

Concurrent treatment with SSRI

Ongoing care with a Primary Care MD on site.

Monitoring

Monitor vital signs and cardiac function. Blood pressure, pulse, breathing, and oxygen saturation always need to be monitored when using ketamine.

Neuropsychiatric function always requires monitoring, and a patient must be at baseline before discharge from care. Even after a patient’s return to baseline, the patient discharge should be under the supervision of another responsible adult. Patients should not drive, use heavy machinery, or perform other potentially hazardous activities for 24 hours following ketamine administration.Ketamine Steven B. Rosenbaum; Vikas Gupta; Jorge L. Palacios. https://www.ncbi.nlm.nih.gov/

A Review of Nonanesthetic Uses of Ketamine

Contraindications

Ketamine is contraindicated in those patients who have underlying conditions in which increased blood pressure would pose a risk of complications such as aortic dissection, uncontrolled hypertension, myocardial infarction, or aneurysms.

  • It is contraindicated in those who have shown prior hypersensitivity to the drug.
  • It is not recommended for use during obstetrics, pregnancy, or for women who are breastfeeding as it is unknown if this medication passes into breast milk. 
  • Use in chronic alcoholics and the acutely alcohol-intoxicated patient may cause death.  
  • It is contraindicated in patients with schizophrenia due to the potential for exacerbating the underlying condition.
  • Ketamine Steven B. Rosenbaum; Vikas Gupta; Jorge L. Palacios. https://www.ncbi.nlm.nih.gov/

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