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Compounded Oral Ketamine for Severe Depression, Anxiety, and Pain in a Hospice Patient with End-stage Chronic Obstructive Pulmonary Disease, Cardiopulmonary Failure, and Severe Renal Insufficiency: A Case Report
Author(s): McNulty Jack P, Hahn Kristian
Issue: Sep/Oct 2012 - Volume 16, Number 5
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Note: Electronic version includes errata or revisions.
Abstract: The nonnarcotic, nonaddictive neuropathic pain reliever ketamine, which was synthesized in the early 1960s by Parke-Davis, was first administered to human patients in 1965. Used by the U. S. military as a field anesthetic during the Vietnam War, it slowly became popular as both an induction and maintenance agent for the general anesthesia required during brief surgical procedures. The use of ketamine in the past has been limited primarily to intravenous administration in hospitalized patients. Very recently, several published reports have described the use of low-dose ketamine for the relief of pain, refractory depression, and anxiety in patients with or without cancer. Because chronic pain, depression, and anxiety often occur in hospice patients with or without cancer and in palliative care patients who are not eligible for hospice, the discovery of new and effective uses for an established drug to treat those conditions has excited interest in the palliative care community. We support that interest with this case report, which describes our experience in treating a 44-year-old male hospice patient with severe constant anxiety, fear, and depression in addition to multiple near-terminal comorbid physical conditions that produce chronic pain. Prior treatments prescribed to resolve this patient’s pain, anxiety, and depression had proven ineffective. However, a single low-dose (0.5 mg/kg) subcutaneous test injection of ketamine provided dramatic relief from those symptoms for 80 hours, although the anesthetic effects of that drug are not of long duration. This good outcome has been sustained to date by daily treatment with a compounded flavored oral ketamine solution (40 mg/5 mL) that is not commercially available. Flavoring the solution masks the bitter taste of ketamine and renders the treatment palatable. We found ketamine to be a well-tolerated and effective treatment for the triad of severe anxiety, chronic pain, and severe depression in a hospice patient with multiple comorbid conditions. To our knowledge, this report chronicles the first use of compounded oral ketamine for home-based palliative or hospice care in Louisiana. A formulation for a flavored oral ketamine solution is provided for easy reference.
Related Keywords: Jack P. McNulty, MD, FACP, FAAHPM, Kristian Hahn, PharmD, ketamine, formulation, palliative care, pain relief, pain control, analgesic, analgesia, anesthetic, neuropathic pain, case report, route of administration
Related Categories: FORMULATIONS, HOSPICE/PALLIATIVE CARE, MENTAL HEALTH, PAIN MANAGEMENT, CASE REPORTS