Intravenous Ketamine “Burst” for Refractory Depression in a Patient with Advanced Cancer

Abstract

Major Depressive Disorder (MDD) is prevalent in patients with advanced cancer, and can have a negative impact on patients' quality of life. Available antidepressants, often have delayed benefits of several weeks, and therefore are of limited utility in the palliative care setting. Psychostimulants provide more rapid onset of action, but frequently require dose escalation because of problems with tolerance. There is a growing body of evidence that N-methyl-D-aspartate (NMDA) receptor antagonists, such as ketamine, signficantly and rapidly improve depressive symptoms in treatment resistant depression. However, studies conducted to date have not included advanced cancer patients. We report on a case where intravenous ketamine 'bursts' (0.5 mg/kg infused over 60 minutes) were used to treat an intractable MDD in a patient with metastatic prostate cancer. Initial positive response was not sustained, and response to a repeat treatment was even more transient. Adverse effects were mild and self-limiting. We conclude that a well-designed, randomized study of IV ketamine "bursts" in cancer patients suffering from depression is needed to further establish the role and appropriate dosing of ketamine in this patient population. Given that ketamine can be used as an adjuvant for difficult pain syndromes in cancer patients, it would be of interest to assess its impact on the mood in patients receiving this treatment for pain.

Daily Oral Ketamine for the Treatment of Depression and Anxiety in Patients Receiving Hospice Care: A 28-Day Open-Label Proof-of-Concept Trial

“…[18][19][20][21][22][23][24][25][26][27][28][29][30][31] Other than two case reports, [32][33][34] no studies to date have examined ketamine's role in treating depression or anxiety in the hospice population. To our knowledge, no investigations of depression treatment for any population have been carried out with oral ketamine, and only a couple investigations of ketamine have assessed symptoms of anxiety.…”

Oral Ketamine for the Rapid Treatment of Depression and Anxiety in Patients Receiving Hospice Care

“…[15][16][17][18][19][20][21] A single case using IV ketamine to treat depression in a patient with advanced cancer has been reported. 22 No studies to date have examined ketamine's role in treating depression in the hospice population. To our knowledge, no investigations of depression treatment for any population have been carried out with oral ketamine, nor have any investigations with ketamine assessed symptoms of anxiety.…”

“…Ketamine's effects on depression have been observed to be relatively long-lasting, although not in every case. 22 Significant literature supports its safe use in hospice patients for other symptoms, including pain. [23][24][25][26][27][28][29][30][31][32] The cases presented here involved subjects in an on-going open label study that is approved by both the Institute for Palliative Medicine Institutional Review Board and the University of California, San Diego Human Research Protection Program.…”

Ketamine and other potential glutamate antidepressants

“…One study used midazolam as an active placebo with no saline control group (Murrough et al, 2013a). A number of trials allowed the use of concomitant medications including other antidepressants (Kudoh et al, 2002;Stefanczyk-Sapieha et al, 2008;Diazgranados et al, 2010v;Irwin and Iglewicz, 2010;Rasmussen et al, 2013). A number of studies had MDD patients with comorbid anxiety disorders (Salvadore et al, 2009;Salvadore et al, 2010;Valentine et al, 2011).…”