Case Report: Ketamine for Pain and Depression in Advanced Cancer

This case report explores the potential of ketamine (35mg/70kg) for pain and depression in advanced cancer. It demonstrated how a patient suffering from neuropathic pain from advanced cancer and severe depression showed a dramatic decrease in pain and resolution of severe depression symptoms post an intravenous infusion of ketamine.

Abstract

“Introduction: Patients with advanced cancer often suffer from both severe pain and severe symptoms of depression. Use of traditional antidepressants is often limited by the short prognosis associated with advanced cancer.

Case report: We present the case of a patient with neuropathic pain from advanced cancer and severe depression that responded dramatically to an intravenous infusion of ketamine resulting in decreased pain and resolution of severe depression symptoms.”

Authors: Jessica Sexton, Rabia S. Atayee & Heather C. Bruner

Summary

Patients with advanced cancer often suffer from both severe pain and severe symptoms of depression. Ketamine decreased pain and resolved severe depression symptoms.

Keywords: ketamine, depression, pain, pharmacology

Introduction

Patients with advanced-stage cancer who have ex-periodic treatment options often suffer from physical pain and psychological issues that can greatly impact quality of life. Opioid therapy may cause various side effects and carry the risk of misuse and abuse.

Ketamine is an alternative agent that has been studied for off-label use in both pain and depression.

Ketamine acts on a variety of receptors, including cholinergic, serotonin, norepinephrine, dopamine, L-type calcium and sodium channels, and opioid receptors, to relieve pain.

Ketamine is an attractive candidate for treatment of depression and/or pain in terminal patients, as it produces a rapid antidepressant effect and has a short lasting effect. However, there are currently no guidelines recommending the use of ketamine in the setting of depression at the end of life.

Case Presentation

A 64-year-old man with metastatic anaplastic thyroid cancer was admitted to the emergency department with syncope, hematochezia, and elevated lactate. He was also receiving fluconazole, a potent cytochrome p450 inhibitor for oral thrush.

The Doris A. Howell Palliative Care Service evaluated a patient with thyroid cancer on hospital day 3 and determined that he had a palliative performance status of 40% and an ECOG performance grade of 3, suggesting a prognosis of less than six months.

The patient was admitted to the hospital with moderate posterior and lateral right neck pain and severe odynophagia upon swallowing. He had been placed on methadone by his outpatient oncologist and expressed a desire to stop all treatment.

A patient with severe depression was evaluated by a palliative psychiatry team after his wife reported that he was not himself anymore and wished to die. The patient scored 24 out of possible 27 on the Patient Health Questionnaire 9.

The patient, in severe psychological distress, requested that the palliative care team hasten his death or put him to sleep. The LCSW inquired whether improving his physical symptoms might alter his desire for hastened death.

A patient with severe neuropathic pain and severe depression was treated with IV ketamine at 0.2 mg/kg/h. The ketamine regimen improved his severe depression and allowed for the discontinuation of his methadone.

A continuous infusion of ketamine was initiated at 17:00 on hospital day 4, and the patient achieved a documented pain score of 0/10 by 21:00 on hospital day 5.

The patient was smiling and saying that he felt better, and was joking with the palliative care team and engaging in conversation. He did not ask for hastened death or palliative sedation, and his wife thanked the team for bringing him back.

The patient was discharged with home hospice after receiving a peripherally inserted central catheter. He remained on ketamine infusion until his peaceful death at home approximately two weeks later.

Discussion

Major depressive disorder (MDD) is common in patients with advanced cancer, but traditional antidepressants may not be effective because of the shortened life span associated with advanced cancer. Palliative care providers have sought alternative treatments for depression in patients with advanced cancer, such as methylphenidate.

Ketamine, a powerful noncompetitive NMDA-receptor antagonist, has been used in palliative care to rapidly ameliorate depression symptoms in patients with advanced cancer. Two patients received a single oral dose of ketamine and experienced subjective and objective improvement in depression and anxiety within hours of administration.

In a patient with metastatic prostate cancer, 0.5 mg/kg IV over 60 minutes improved depression scores within hours, but the effect was not sustained.

A 36-year-old woman with metastatic ovarian cancer receiving chemotherapy experienced significant relief of depressive symptoms within one hour after receiving the first injection of IM ketamine. The patient did not experience tachyphylaxis to the antidepressant effects with repeated IM dosing.

Although there is little data on the prevalence of depression in advanced cancer patients, and even less data on the frequency with which cancer patients are appropriately treated for depression at the end of life, the potential impact on survivors is unknown.

A cancer patient who experienced pain and depression symptoms so severe that he requested hastened death experienced rapid, significant, and sustained improvement with a continuous IV infusion of ketamine.

Ketamine may be used to treat depression in patients with advanced cancer, but a well-designed randomized study is needed to address ideal dosing.