ketamine infusion adjuvant medications (final) · 2019. 11. 14. · • ondansetron (zofran) –...
TRANSCRIPT
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Medications Used During Ketamine Infusion Therapy
Designed to Improve Outcomes in Patients with
CRPS
Medications Used During Ketamine Infusion Therapy
Designed to Improve Outcomes in Patients with
CRPS
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Alpine Health & WellnessAlpine Health & Wellness
• Jeffrey Kesten, MD– Medical Director
• Kristen Johnson– Vice-President and Director of the Ketamine
Infusion Center
3955 E. Exposition Avenue, Suite 505, Denver, CO 80209(720)519-0678jeffreykestenmd.com
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Alpine Health & WellnessAlpine Health & Wellness
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Adjuvant Medications in Ketamine Infusion Therapy
Adjuvant Medications in Ketamine Infusion Therapy
• Adjuvant – A substance that helps and enhances the effect of a drug, treatment, or biological system
• Debate persists regarding ketamine dosing protocols
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Adjuvant Medications in Ketamine Infusion Therapy
Adjuvant Medications in Ketamine Infusion Therapy
• Many medications may be used during ketamine infusion therapy that– Mitigate or eliminate associated side effects– Improve pain– Optimize overall outcomes– Are often used off-label
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Side Effects Associated with Ketamine Infusion Therapy
Side Effects Associated with Ketamine Infusion Therapy
• “May be present during administration, but rapidly dissipate upon termination of treatment”
Jonkerman K. et al. (September 2017)
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Adjuvant Medications in Ketamine Infusion Therapy
Adjuvant Medications in Ketamine Infusion Therapy
• It is critical that the patient’s overall experience to ketamine infusion therapy be as safe and comfortable as possible to ensure optimal outcomes
• Treatment options for patients with CRPS are often limited and suboptimally effective in managing their symptoms
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Adjuvant Medications in Ketamine Infusion Therapy
Adjuvant Medications in Ketamine Infusion Therapy
• An optimal and customized environment in which patients undergo ketamine infusion therapy is necessary for patients to achieve the best outcomes possible
• Mindful customization of patients’ adjunctive medications in ketamine infusion therapy is a critical consideration in this process
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Adjuvant Medications in Ketamine Infusion Therapy
Adjuvant Medications in Ketamine Infusion Therapy
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Conditions that May Be Managed by Adjuvant
Medications During Ketamine Infusion Therapy
Conditions that May Be Managed by Adjuvant
Medications During Ketamine Infusion Therapy
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Alpine Health & WellnessAlpine Health & Wellness
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Conditions Managed by Adjuvant Medications During KIT
Conditions Managed by Adjuvant Medications During KIT
• Psychological effects• Euphoria (“drug high”)• Nausea, vomiting, and
dyspepsia (upset stomach)• Hypertension (high blood
pressure)• Tachycardia (fast heart rate)• Headache
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Psychological EffectsPsychological Effects
• Hallucinations/synesthesias• Paranoia• Derealization/depersonalization• Anxiety • Panic attacks• Emergence agitation
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Psychological EffectsPsychological Effects
• Synesthesia– A medical condition in which one of the five senses
stimulates another sense• Examples
– Sound may produce the visualization of color
– Letters of the alphabet may produce particular scents
– Taste may present as a complex mixture of temperature and texture
– Can be induced by ketamine– More common in females
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Psychological EffectsPsychological Effects
• Emergence agitation– A state of nonpurposeful
restlessness, noncooperation, and inconsolability
– Often accompanied by crying, screaming, thrashing,and disorientation
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Psychological EffectsPsychological Effects
• Medication classes to be considered– Benzodiazepines– Alpha-2 receptor agonists– Antipsychotics (neuroleptics)– Antihistamines
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Psychological EffectsPsychological Effects
• Benzodiazepines– Description
• Primarily used for the treatment of anxiety and muscle spasm• May cause short-term amnesia• Varying potency and duration of action
– Mechanism of action• Affects neurotransmitters in the brain, chemicals that nerves
release in order to communicate with other nearby nerves• Modulates the GABA-A receptor• GABA-A receptor is a ligand-gated chloride-selective ion
channel
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Psychological EffectsPsychological Effects
• Benzodiazepines commonly used in ketamine infusion therapy– Diazepam (Valium)– Lorazepam (Ativan)– Midazolam (Versed)
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Psychological EffectsPsychological Effects
• Diazepam (Valium)– Formulations
• Oral, sublingual, intramuscular, and intravenous– Characteristics
• Long-acting– Pharmacokinetics (what the body does to a medication)
• Oral and intravenous onset of action within 15 minutes• Peak onset (oral) 1 hour• Half-life 20-50 hours
– Side effects, warnings, and precautions• Drowsiness, dizziness, tiredness, blurred vision, and respiratory
depression
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Psychological EffectsPsychological Effects
• Lorazepam (Ativan)– Formulations
• Oral, sublingual, intramuscular, and intravenous
– Characteristics• Short-acting
– Pharmacokinetics (what the body does to a medication) • Intermediate-acting• Intravenous onset of action within 15 minutes (rapid)• Half-life 1-4 hours
– Side effects, warnings, and precautions• Drowsiness, dizziness, tiredness, blurred vision, and respiratory depression
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Psychological EffectsPsychological Effects
• Midazolam (Versed)– Formulations
• Intramuscular and intravenous– Characteristics
• Short-acting– Pharmacokinetics (what the body does to a medication)
• Intravenous onset of action within 15 minutes (most rapid)• Peak onset (intravenous) 0.5-1.5 hours• Half-life 1-4 hours
– Side effects, warnings, and precautions• Drowsiness, dizziness, tiredness, blurred vision, and respiratory
depression
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Psychological EffectsPsychological Effects
• Alpha-2 agonists – Description
• Decreases norepinephrine (adrenaline) in the brain• Decreases arterial pressure
– Mechanism of action• Selectively blocks the sympathetic
nervous system• Decreases norepinephrine release in
the brain• Decreases arterial pressure
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Psychological EffectsPsychological Effects
• Clonidine– Formulations
• Oral and transdermal (topical)
– Characteristics• Sedative and anti-anxiety actions• Reinforces the pain-alleviating effects of morphine• Acts rapidly with blood pressure declines in 30-60 minutes
after an oral dose, the maximum decrease occurring within 2-4 hours
– Side effects, warnings, and precautions • Dry mouth, drowsiness, dizziness, constipation, and sedation
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Psychological EffectsPsychological Effects
• Alpha-2 agonists commonly used in ketamine infusion therapy – Clonidine (Catapres)– Dexmedetomidine (Precedex)– Tizanidine (Zanaflex)
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Psychological EffectsPsychological Effects
• Dexmedetomidine (Precedex)– Formulation
• Intravenous
– Characteristics• Among the most active in this medication class• Slow infusion • Sedatives/hypnotics (e.g. midazolam) and opioids can
enhance the sedating effects of dexmedetomidine• Anti-anxiety properties• Analgesic (pain-reducing) characteristics
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Psychological EffectsPsychological Effects
• Dexmedetomidine (Precedex)– Side effects, warnings, and precautions
• Slow heart rate and cardiac arrest• Increased risk – Elderly, advanced heart block, dehydration, chronic
high blood pressure (hypertension), and diabetes mellitus• Respiratory depression• Low blood pressure
(hypotension)• Short-term high blood pressure
(hypertension)
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Psychological EffectsPsychological Effects
• Antipsychotics (neuroleptics)– Description
• Antipsychotic medication used to treat schizophrenia• Particularly effective in managing hyperactivity, agitation, and
mania• Possess anti-nausea properties• Tendency to provoke certain movement disorders (i.e.
extrapyramidal effects)
– Mechanism of action• Primarily blocks dopamine receptors • Secondarily, it blocks certain serotonin receptors
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Psychological EffectsPsychological Effects
• Antipsychotics (neuroleptics) used in ketamine infusion therapy– Haloperidol (Haldol)– Aripiprazole (Abilify)
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Psychological EffectsPsychological Effects
• Haloperidol (Haldol)– Formulations
• Oral, intramuscular, and intravenous
– Characteristics• Mechanism of action not clearly established• Indicated for the treatment of schizophrenia and Tourette’s
disorder• Associated with a particular movement disorder (i.e. tardive
dyskinesia)– Potentially irreversible– Incidence increases as duration of treatment and cumulative exposure
increases– Although uncommon, can develop after brief periods at low doses
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Psychological EffectsPsychological Effects
• Haloperidol (Haldol)– Side effects, warnings, and precautions
• Irregular heartbeat• Movement disorders (i.e. tardive dyskinesia)• Severe cardiovascular disease
– Possibility of transient low blood pressure (hypotension)– Chest pain (angina pectoris)
• May lower seizure threshold
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Psychological EffectsPsychological Effects
• Aripiprazole (Abilify)– Formulations
• Oral and sublingual– Characteristics
• Mechanism of action is unclear• May work on specific dopamine and serotonin
receptors
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Psychological EffectsPsychological Effects• Aripiprazole (Abilify)
– Side effects, warnings, and precautions• Stroke in elderly people• Movement disorders (i.e. tardive dyskinesia)• Increased blood sugar• Lowers seizure threshold• Low blood pressure• Neuroleptic malignant syndrome (NMS)
– Characterized by high fever, stiff muscles, confusion, sweating, and/or changes in heart rate and blood pressure
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Psychological EffectsPsychological Effects
• Antihistamines– Description
• Compounds that oppose the effects of histamine• Often used to treat allergies• Sedative effects
– Mechanism of action• Antihistamine• Anticholenergic
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Psychological EffectsPsychological Effects
• Antihistamine used in ketamine infusion therapy– Diphenhydramine (Benadryl)
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Psychological EffectsPsychological Effects
• Diphenhydramine (Benadryl)– Side effects, warnings and precautions
• Generally safe• Can dose up to 400 mg• Dry mouth, nose, and throat• Drowsiness• Dizziness• Constipation• Stomach upset• Blurred vision
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EuphoriaEuphoria
• Definition– A feeling or state of intense excitement and
happiness• Generally not problematic• When uncomfortable, manage with similar
medications used in treating psychological side effects
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Description– Antiemetics are drugs that are effective in
treating nausea and vomiting– Used to treat side effects of medications and
motion sickness– Another class of medications is used to treat
certain conditions of the stomach and intestines (increases muscle contractions in the upper digestive tract)
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Medications used to manage nausea, vomiting and dyspepsia (upset stomach) in ketamine infusion therapy– Ondansetron (Zofran)– Promethazine (Phenergan)– Metaclopramide (Reglan)
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Ondansetron (Zofran)– Formulations
• Oral, sublingual, intramuscular, and intravenous– Mechanism of action
• Blocks the action of serotonin, a natural substance that may cause nausea and vomiting
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Ondansetron (Zofran)– Side effects, warnings, and precautions
• ECG changes (e.g. QT interval prolongation)• Serotonin syndrome
– Mental status changes (e.g. agitation, hallucinations, delirium, and coma)
– Problems with the autonomic nervous system (e.g. rapid heart rate, erratic blood pressure, dizziness, sweating, flushing, and fever)
– Seizures– Neuromuscular symptoms (e.g. tremor, rigidity, overactive reflexes, and
problems with coordination)– Gastrointestinal symptoms (e.g. nausea, vomiting, and diarrhea)
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Ondansetron (Zofran)• Diarrhea• Headache• Fever• Lightheadedness/dizziness• Weakness• Tiredness/drowsiness• Constipation• Rash• Muscle Spasm
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Promethazine (Phenergan)– Formulations
• Oral, rectal, intramuscular, and intravenous
– Mechanism of action• Antipsychotic (phenothiazine) derivative• Antihistamine
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Promethazine (Phenergan)– Side effects, warnings, and precautions
• Sedation• Respiratory depression• Lowers seizure threshold• Neuroleptic malignant syndrome (NMS)
– Characterized by high fever, stiff muscles, confusion, sweating, and/or changes in heart rate and blood pressure
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Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
– Promethazine (Phenergan) • Side effects, warnings and precautions
– Specific movement disorders (i.e. tardive dyskinesia and other extrapyramidal effects)
– Neuroleptic malignant syndrome (NMS)» Characterized by high fever, stiff muscles, confusion,
sweating, and/or changes in heart rate and blood pressure– High blood pressure (hypertension)– Fluid retention– Lowers seizure threshold
![Page 45: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/45.jpg)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
• Metaclopramide (Reglan)– Formulations
• Oral, sublingual, intramuscular, and intravenous
– Mechanism of action• Blocks dopamine receptors
– Warnings and precautions• Specific movement disorders (tardive dyskinesia and other
extrapyramidal effects)• Neuroleptic malignant syndrome (NMS)• High blood pressure (hypertension)• Fluid retention• Lowers seizure threshold
![Page 46: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/46.jpg)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)
Nausea, Vomiting, and Dyspepsia (Upset Stomach)– Metaclopramide (Reglan)
• Side effects, warnings, and precautions• Specific movement disorders (tardive dyskinesia
and other extrapyramidal effects)• Neuroleptic malignant syndrome (NMS)
– Characterized by high fever, stiff muscles, confusion, sweating, and/or changes in heart rate and blood pressure
• High blood pressure (hypertension)• Fluid retention• Lowers seizure threshold
![Page 47: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/47.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Description– Not an uncommon side effect of ketamine infusion
therapy– Medications include those specifically designed to
lower blood pressure – High blood pressure in ketamine infusion therapy may
be due to• Effects of ketamine• Anxiety and/or agitation
– Other medications are helpful in managing high blood pressure by reducing anxiety and agitation
![Page 48: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/48.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Medications used to manage hypertension (high blood pressure) in ketamine infusion therapy– Clonidine (Catapres)– Labetalol– Dexmedetomidine (Precedex)– Benzodiazepines
![Page 49: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/49.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
– Clonidine (Catapres)• Formulations
– Oral and topical
• Mechanism of action– Blocks the sympathetic nervous system
![Page 50: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/50.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Clonidine (Catapres)– Side effects, warnings, and precautions
• Dry mouth• Tiredness• Weakness• Headache• Nervousness• Nausea and vomiting• Constipation• Hypotension (low blood pressure)• Slow heart rate
![Page 51: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/51.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Labetalol– Formulations
• Oral and intravenous– Mechanism of action
• Beta blocker
![Page 52: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/52.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Labetalol– Side effects, warnings, and precautions
• Congestive heart failure• Irregular heart rate (i.e. arrhythmia)• Coronary artery disease/history of heart attack• Poorly-controlled diabetes mellitus• Hypotension (low blood pressure)
![Page 53: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/53.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
– Dexmedetomidine (Precedex)• Formulation
– Intravenous• Mechanism of action
– Stimulates the alpha-2 adrenergic receptors
![Page 54: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/54.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Dexmedetomidine (Precedex)– Side effects, warnings, and precautions
• No contraindications• Slow heart rate• Hypotension (low blood pressure)• Cardiac arrest• Caution in patients with advanced heart block• Transient hypertension (high blood pressure)
![Page 55: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/55.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
– Benzodiazepines• Formulations
Oral, sublingual, intramuscular, and intravenous
• Mechanism of action– Enhances the inhibitory actions
of the neurotransmitter GABA
![Page 56: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/56.jpg)
Hypertension (High Blood Pressure)
Hypertension (High Blood Pressure)
• Benzodiazepines– Side effects, warnings, and precautions
• Drowsiness, dizziness, tiredness, blurred vision, and respiratory depression
![Page 57: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/57.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
• Description– Similar to managing high blood pressure in
ketamine infusion therapy, medications used to manage tachycardia (fast heart rate) in ketamine infusion therapy include
• Medications indicated to lower heart rate• Medications that may lower heart rate by reducing
anxiety and agitation
![Page 58: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/58.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
• Medications used to manage tachycardia (fast heart rate) in ketamine infusion therapy– Clonidine (Catapres)– Labetalol– Dexmedetomidine (Precedex)– Benzodiazepines
![Page 59: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/59.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
– Clonidine (Catapres) • Formulations
– Oral and topical• Mechanism of action
– Blocks the sympathetic nervous system
![Page 60: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/60.jpg)
Tachycardia (Fast Heat Rate)Tachycardia (Fast Heat Rate)
• Clonidine (Catapres)• Side effects, warnings, and precautions• Dry mouth• Tiredness• Weakness• Headache• Nervousness• Nausea and vomiting• Constipation• Hypotension (low blood pressure)• Slow heart rate
![Page 61: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/61.jpg)
Tachycardia (Fast Heart Rate) Tachycardia (Fast Heart Rate)
– Labetolol• Formulations
– Oral and intravenous• Mechanism of action
– Beta blocker
![Page 62: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/62.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
• Labetalol– Side effects, warnings, and precautions
• Congestive heart failure• Irregular heart rate (i.e. arrhythmia)• Coronary artery disease/history of heart attack• Poorly-controlled diabetes mellitus• Hypotension (low blood pressure)
![Page 63: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/63.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
– Dexmedetomidine (Precedex)• Formulation
– Intravenous• Mechanism of action
– Stimulates the alpha-2 adrenergic receptors
![Page 64: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/64.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
• Dexmedetomidine (Precedex)– Side effects, warnings, and precautions
• Slow heart rate and cardiac arrest• Increased risk – Elderly, advanced heart block, dehydration,
chronic high blood pressure (hypertension), and diabetes mellitus
• Respiratory depression• Low blood pressure (hypotension)• Short-term high blood pressure (hypertension)
![Page 65: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/65.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
– Benzodiazepines• Formulations
– Oral, sublingual, intramuscular, and intravenous• Mechanism of action
– Enhances the inhibitory actions of the neurotransmitter GABA
![Page 66: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/66.jpg)
Tachycardia (Fast Heart Rate)Tachycardia (Fast Heart Rate)
– Benzodiazepines• Side effects, warnings, and precautions
– Drowsiness, dizziness, tiredness, blurred vision, and respiratory depression
![Page 67: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/67.jpg)
HeadacheHeadache
• Description– Not an uncommon side effect of ketamine infusion
therapy– May persist after completion of ketamine infusion
therapy (not uncommon the evening after undergoing KIT)
– Characteristics• Involves the entire head• Dissimilar to migraine headache• Responds well to Fioricet (butalbital 50 mg/acetaminophen
300 vs 325 mg/caffeine 40 mg)
![Page 68: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/68.jpg)
HeadacheHeadache
• Medication used to manage headache in ketamine infusion therapy– Fioricet (butalbital 50 mg/ acetaminophen 300
mg vs 325 mg/caffeine 40 mg)
![Page 69: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/69.jpg)
HeadacheHeadache
• Fioricet (butalbital 50 mg/acetaminophen 300 mg vs 325 mg/caffeine 40 mg)– Formulation
• Oral
– Mechanism of action• Several mechanisms of action as this medication consists of
combination of 3 distinct medications (multi-modal)– Barbiturate– Pain-reliever (analgesic)– Constricts blood vessel in the brain
![Page 70: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/70.jpg)
HeadacheHeadache
• Fioricet– Constituents and mechanisms of action
• Butalbital– Barbiturate– Nonselective depressant effect on the central nervous system– Sedative and hypnotic effects
• Acetaminophen– Acts primarily in the central nervous system– Alleviates pain
• Caffeine– Constricts blood vessels in the brain– Counteracts the sedative effects of butalbital
![Page 71: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/71.jpg)
HeadacheHeadache
• Fioricet (butalbital 50 mg/acetaminophen 300 mg vs 325 mg/caffeine 40 mg)– Side effects, warnings, and precautions
• Extended use is not recommended as it is habit-forming
• Precautions for– Elderly– Debilitated– Severe kidney or liver disease
• May cause increased central nervous system depression
![Page 72: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/72.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
• Low-level evidence and often anecdotal• Medications used to improve pain relief in
ketamine infusion therapy– Dextromethorphan– Lidocaine– Magnesium– Ketorolac (Toradol)
![Page 73: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/73.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
– Dextromethorphan• Formulation
– OralMechanism of action
– Binds to the NMDA receptor (implicated in reducing pain)
• May cause hallucinations, confusion, agitation, muscle twitching, overactive reflexes, shivering, and rapid heart rate
![Page 74: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/74.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
– Dextromethorphan• Formulation
– Oral• Mechanism of action
– Binds to the NMDA receptor (implicated in reducing pain)
![Page 75: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/75.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
• Dextromethorphan– Side effects, warnings and precautions
• Hallucinations• Confusion• Agitation• Muscle twitching• Overactive reflexes• Shivering• Rapid heart rate
![Page 76: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/76.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
• Magnesium– Formulation
• Oral and intravenous– Mechanism of action
• Binds to the NMDA receptor and may enhance the pain-relieving effects of ketamine
– Side effects• May include heart disturbances, breathing
difficulties, confusion, weakness, flushing, sweating, and low blood pressure
![Page 77: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/77.jpg)
Miscellaneous Medication Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medication Purported to Improve Pain Relief in Ketamine Infusion
Therapy
• Magnesium– Side effects, warnings, and precautions
• Heart disturbances• Breathing difficulties • Confusion• Weakness• Flushing• Sweating• Low blood pressure
![Page 78: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/78.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
• Ketorolac (Toradol)– Formulation
• Topical, oral, intramuscular, and intravenous
– Mechanism of action• Non-steroidal anti-inflammatory
drug
![Page 79: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/79.jpg)
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
Miscellaneous Medications Purported to Improve Pain Relief in Ketamine Infusion
Therapy
• Ketorolac (Toradol)– Side effects, warnings, and contraindications
• History of peptic ulcer disease or gastrointestinal bleeding• Contraindicated in the setting of coronary artery bypass graft
surgery including previous heart attack• Warning with heart failure or edema• Advanced kidney and/or liver disease• Hemorrhage• Consuming aspirin or other non-steroidal anti-inflammatory
drugs• New high blood pressure or worsening of previous high blood
pressure• Not to consume 5 days
![Page 80: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/80.jpg)
The Big PictureThe Big Picture
• Ketamine infusion therapy remains a promising treatment in managing CRPS symptoms
• In addition to non-pharmacologic considerations necessary to enhance ketamine infusion therapy outcomes, optimizing adjuvant medication therapy in ketamine infusion therapy is crucial in improving pain relief and limiting side effects
• There is hope!
![Page 81: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/81.jpg)
The Bottom LineThe Bottom Line
• Everyone is unique when it comes to finding the right infusion “cocktail”
• Interview your ketamine infusion center first and see what they are or are not willing to offer
![Page 82: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/82.jpg)
The Bottom LineThe Bottom Line
• Be patient – Sometimes it a takes a few infusions to find out what works best for you!
• Make sure your infusion center is familiar with CRPS and uses a CRPS protocol and not a depression protocol. Don’t waste your time or money!
![Page 83: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/83.jpg)
The Bottom LineThe Bottom Line
![Page 84: Ketamine Infusion Adjuvant Medications (final) · 2019. 11. 14. · • Ondansetron (Zofran) – Side effects, warnings, and precautions • ECG changes (e.g. QT interval prolongation)](https://reader033.vdocuments.us/reader033/viewer/2022052022/60374f3e9d0b2a1008254d3c/html5/thumbnails/84.jpg)
Thank you!Thank you!