Management of complications of ketamine abuse: 10 years’ experience in Hong Kong

Hong, Yan; Yee, Chi‐Hang; Tam, Y. H.; Wong, Jennie; Lai, P. T.; Ng, Chi‐Fai

doi:10.12809/hkmj177086

Cited by 19 publications

(30 citation statements)

References 28 publications

(42 reference statements)

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“…It is abused as a recreational drug and can cause addiction [31]. The abuse of ketamine is associated with urological, neuropsychiatric, hepatobiliary and gastrointestinal complications [32]. In the treatment of depressive or anxious patients, racemic ketamine (0.50 mg/kg), as an i. v. infusion lasting 40 min, has an anti-depressive and anxiolytic effect [33,34].…”

Section: Introductionmentioning

confidence: 99%

A rapid positive influence of S-ketamine on the anxiety of patients in palliative care: a retrospective pilot study

et al. 2020

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Background: Patients in palliative care need rapid-acting pharmacological options for psychological distress. Nmethyl-D-aspartate antagonist ketamine is known to have a fast onset of anti-depressant and anxiolytic action. Its Senantiomer S-ketamine (or esketamine) is an analgesic used as a routine treatment for refractory pain as an intravenous infusion (0.25 mg/kg over 45 min). This study investigates whether S-ketamine pain therapy has a positive impact on psychological distress caused by anxiety and depression in palliative care. Methods: Patient routine data from a palliative care unit of a tertiary care hospital were used in a retrospective analysis after positive ethics approval. Eight patients, who received analgesic S-ketamine treatment, were compared to a control group matched by gender and age. The main analysis was conducted using three-way mixed MANOVA followed by two-way mixed ANOVA. Target variables were the values for anxiety and depression in the state-trait anxiety-depression inventory STADI. The predictor variables were the time of measurement before (T1) and after (T2) S-ketamine application and group membership. Results: Comparison of the S-ketamine group (n = 8; 4 male, 4 female; average age 52 years) with the control group (n = 8; 3 male, 5 female; average age 55 years) revealed a significant multivariate effect on anxiety and depression F(1, 14) = 4.78; p = 0.046; r = 0.50. The univariate comparisons showed a significant reduction of the anxiety scores from T1 to T2 in the S-ketamine group compared to the control group F(1, 14) = 10.14; p = 0.007; r = 0.65. With regard to depression, there was no significant reduction from T1 to T2 in the group comparison F(1, 14) = 1.60; p = 0.23; r = 0.32. No long-lasting effects on pain were found. Conclusions: Our findings show that psychological distress of patients in palliative care may improve after a single administration of S-ketamine, which mainly alleviates anxiety in those patients. Limitations of this study arise from non-randomization, retrospective analysis and low sample size. Therefore, further prospective and ideally randomized studies are necessary.

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Section: Introductionmentioning

confidence: 99%

A rapid positive influence of S-ketamine on the anxiety of patients in palliative care: a retrospective pilot study

et al. 2020

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“…Figure 2 shows the suggested diagnostic and therapeutic approaches. An initial evaluation with urine microscopy and culture, voiding diary, questionnaire assessment of symptoms and renal ultrasound is recommended to rule out infections, and to evaluate bladder capacity, upper tract involvement and LUTS 3‐5,65,67,74 . CT scan should be performed to clarify hydronephrosis better.…”

Section: Discussionmentioning

confidence: 99%

“…Ketamine abstinence is the first step in successfully managing KIU and should be achieved in all patients to obtain symptoms improvement, medical therapy effectiveness, and break the chain of urinary tract destruction 3‐5,64,65,74 . Symptoms usually tend to improve over time after ketamine cessation in earlier and less severe cases, but often relapse in case of resumption 3,5,15,61,74,75 . Ketamine abstinence is difficult in many abusers even if they understand the importance of cessation 11 .…”

Section: Evidencementioning

confidence: 99%

What urologists need to know about ketamine‐induced uropathy: A systematic review

Castellani

Pirola

Gubbiotti

et al. 2020

Neurourology and Urodynamics

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Aims: Ketamine is a general anesthetic. Dissociative effects and low cost led ketamine becoming an illegal recreational drug in young adults. Ketamineinduced uropathy (KIU) is one of the complications observed in abusers. This study aimed to provide a systematic literature review on KIU clinical presentation, pathophysiology, and treatments. Methods: We performed the literature search in PubMed, Web of Science, Scopus, and Embase using the terms ketamine and bladder. English papers on human and animal studies were accepted. Results: A total of 75 papers were selected. Regular ketamine users complain about severe storage symptoms and pelvic pain. Hydronephrosis may develop in long-term abusers and is correlated to the contracted bladder, ureteral stenosis, or vesicoureteral reflux due to ureteral involvement and/or bladder fibrosis. Cystoscopy shows ulcerative cystitis. Ketamine in urine might exert direct toxicity to the urothelium, disrupting its barrier function and enhancing cell apoptosis. The presence of ketamine/ions in the bladder wall result in neurogenic/IgE-mediated inflammation, stimulation of the inducible nitric oxide synthase-cytokines-cyclooxygenase pathway with persistent inflammation and fibrosis. Abstinence is the first therapeutic step. Anti-inflammatory drugs, analgesics and anticholinergics, intravesical instillation of hyaluronic acid, hydrodistension and intravesical injection of botulin toxin-A were helpful in patients with early-stage KIU. In patients with end-stage disease, the control of intractable symptoms and the increase of bladder capacity were the main recommendations to perform augmentation enterocystoplasty.Conclusions: KIU is becoming a worldwide health concern, which should be taken into account in the differential diagnosis of ulcerative cystitis. K E Y W O R D S cystitis, inflammation, ketamine, lower urinary tract symptoms, substance-related disorders, urinary tract 1050 | CASTELLANI ET AL.

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“…Ketamine is also indicated to control chronic or acute pain in certain situations, including postoperative, neuropathic, and cancer pain . Unfortunately, ketamine also has become a worldwide recreational drug, especially in Hong Kong, China, Taiwan, and the United Kingdom . Shahani et al first reported severe bladder pain, urinary frequency, urgency, and gross hematuria in patients abusing ketamine.…”

Section: Introductionmentioning

confidence: 99%

“…4 Unfortunately, ketamine also has become a worldwide recreational drug, especially in Hong Kong, China, Taiwan, and the United Kingdom. [5][6][7] Shahani et al 8 first reported severe bladder pain, urinary frequency, urgency, and gross hematuria in patients abusing ketamine. A recent study in Taiwan revealed the prevalence of lower urinary tract symptoms in people with ketamine abuse was greater than 50%.…”

Section: Introductionmentioning

confidence: 99%

Upregulation of neurotrophins and transforming growth factor‐β expression in the bladder may lead to nerve hyperplasia and fibrosis in patients with severe ketamine‐associated cystitis

Jhang

Wang

Hsu

et al. 2019

Neurourology and Urodynamics

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Aims To investigate the mechanism of bladder nerve hyperplasia and fibrosis in the patients with ketamine‐associated cystitis (KC). Methods Sixteen patients with severe KC, six patients with mild KC, and five patients with localized invasive bladder cancer served as control patients. Bladder mucosa specimens were taken during the operations, and the specimens were stained for nerve growth factor (NGF) and S‐100 to evaluated nerve hyperplasia. The quantitative Western blot analysis was performed for NGF, brain‐derived neurotrophic factor (BDNF), growth‐associated protein 43 (GAP‐43), tropomyosin receptor kinase A and B (TrkA and TrkB), transforming growth factor‐β (TGF‐β), phosphorylated extracellular signal‐regulated kinases (p‐ERK), protein kinase B (p‐Akt), and glycogen synthase kinase 3β (p‐GSK‐3β). Results The results demonstrated diffuse NGF expression in KC bladder epithelium, lamina propria, and muscle. The GAP‐43, NGF, BDNF, TrkA, TGF‐β, p‐ERK, P‐AKT, and p‐GSK‐3β expression in the bladder mucosa specimens of patients with severe KC was significantly higher than in patients with mild KC and control patients. Expression of neurotrophins was significantly correlated with bladder capacity and pain. NGF and BDNF expression were significantly higher in the KC bladder specimens with strongly positive S‐100 staining. TGF‐β expression in the bladder specimens was significantly correlated with neurotrophins, p‐ERK, P‐AKT, and p‐GSK‐3β levels. Conclusion Our findings indicate upregulation of neurotrophins, TGF‐β, and activation of the cell proliferation kinases plays an important role in nerve hyperplasia and fibrosis mechanisms in severe KC bladders. The neurotrophins and TGF‐β interact as cause and effect, leading to bladder hypersensitivity and fibrosis in severe KC.

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Management of complications of ketamine abuse: 10 years’ experience in Hong Kong

Cited by 19 publications

References 28 publications

A rapid positive influence of S-ketamine on the anxiety of patients in palliative care: a retrospective pilot study

A rapid positive influence of S-ketamine on the anxiety of patients in palliative care: a retrospective pilot study

What urologists need to know about ketamine‐induced uropathy: A systematic review

Upregulation of neurotrophins and transforming growth factor‐β expression in the bladder may lead to nerve hyperplasia and fibrosis in patients with severe ketamine‐associated cystitis

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