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Long-term ketamine subcutaneous continuous infusion in neuropathic cancer pain
S Mercadante1, F Lodi, M Sapio
1Department of Anesthesia and Intensive Care, Buccheri La Ferla Hospital, Fatebenefratelli, Palermo, Italy.
Abstract:
Neuropathic cancer pain may be less responsive to opioids than other pain. Several studies suggest that N-methyl-D-aspartate (NMDA)-receptor antagonists could play a role in the treatment of neuropathic pain. Ketamine is an NMDA-receptor antagonist that is used as an anesthetic and has been suggested as a useful drug for neuropathic pain. Subanesthetic doses of ketamine can yield analgesia without hypnosis. We describe a patient who developed neuropathic cancer pain unresponsive to opioid escalation and spinal administration of a combination of bupivacaine-morphine and was subsequently treated by subcutaneous continuous ketamine infusion. A starting dose of 150 mg/day provided good pain relief and a dramatic reduction of the oral morphine dose (from 5 g to 200 mg). A slow and progressive increase of ketamine and morphine dosage (400 mg and 200 mg by the subcutaneous route, respectively) continued to provide adequate pain relief after 13 months of therapy despite signs of progressive disease.
Insights
Neuropathic cancer pain can be challenging to treat. Subcutaneous ketamine infusion effectively managed opioid-refractory pain in one patient, reducing morphine needs.
Area of Science:
- Anesthesiology
- Pain Medicine
- Oncology
Background:
- Neuropathic cancer pain often shows limited response to opioids.
- N-methyl-D-aspartate (NMDA)-receptor antagonists are explored for neuropathic pain management.
- Ketamine, an NMDA-receptor antagonist, offers potential analgesic effects at subanesthetic doses.
Observation:
- A patient with severe neuropathic cancer pain was refractory to escalating opioid doses and spinal analgesia (bupivacaine-morphine).
- Continuous subcutaneous ketamine infusion was initiated for pain management.
- The patient experienced significant pain relief and reduced opioid requirements.
Findings:
- A starting dose of 150 mg/day of subcutaneous ketamine provided substantial analgesia.
- Oral morphine dosage was reduced from 5 g to 200 mg daily.
- The treatment regimen, with adjusted ketamine and morphine doses (up to 400 mg and 200 mg/day subcutaneously, respectively), maintained pain control for 13 months, even with disease progression.
Implications:
- Subcutaneous ketamine infusion represents a viable therapeutic option for refractory neuropathic cancer pain.
- This approach can significantly decrease reliance on high-dose opioids.
- Further research into ketamine's role in managing complex cancer pain syndromes is warranted.