S-ketamine as an adjuvant analgesic: effectiveness of oral administration

H. de Graaf-Waar, RN, CNS; P.J. Lieverse, MD; A.J.E.F. de Wit, RN, CNS; L. van Zuylen, MD, PhD
1

Department of Medical Oncology, Department of Anesthesiology, Erasmus MC Daniel den Hoed Cancer Center,

Rotterdam, the Netherlands. H.i.degraaf@erasmusmc.nl

Introduction
S-ketamine (Ketanest-S) is increasingly popular as an adjuvant to opioids in the treatment of cancer pain. The first reason to start with S-ketamine is that it is a possible therapy for neuropathic pain due to nerve damage by a tumor. A second reason to give S-ketamine is to prevent or treat the tolerance to opioids. In case reports and studies it is often administrated parenterally, but there are some reports about oral administration, which is more convenient for the patient. Advices about its dosage vary.

Methods
Retrospectively the medical records were studied of all patients who received S-ketamine orally since we started using this treatment in January 2003. We studied both the patients who received S-ketamine orally from start and those in whom the administration was converted from parenteral to oral administration.

Results
From January 2003 March 2004 14 patients were treated with Sketamine. In 9 of them (64%) S-ketamine was administered orally. All 9 patients were in the palliative phase of advanced cancer and in all cases pain was managed multidisciplinary. They received S-ketamine adjuvant to parenteral or transdermal opioids. Five patients started with parenteral administration of S-ketamine resulting in a pain relief in all. S-ketamine was converted after 4-8 days to oral administration, with a satisfying result in 4 of them. Three patients were able to decrease opioids, 1 patient was able to stop opioids. Four patients started with S-ketamine orally with no pain relief. Three of them shifted to parental S-ketamine with a satisfying effect in only one of them. For 2 patients it was not possible to reach pain relief, despite increasing opioids.

Patient Characterics Gender: 2 male, 7 female Mean age: 60 years (range 43-76)

Diagnosis Melanoma Breast cancer: Lung cancer: Head/neck cancer: Osteo sarcoma 2 2 2 2 1

Opioids Morphine: Fentanyl (t.d.) Hydromorphine: 3 3 2

Epiduraal/ intrathecaal: 1

V
Start S-ketamine start sc Convertion Stop sc to oral iv to oral Oral to sc Oral to iv Total 3 2 3 2 2 1 4 start iv start oral 1 1 3 2 2 Hallucinations: 1 9 2 Total Reason to start S- ketamine Uncontrolled pain: 2

Opioids rescue insufficient: 2 Nausea by opioids: Missing: Side effect of S-ketamine 1 4

Conclusion: S-ketamine is a useful adjuvant to opioids in complex pain problems. It seems rational to try to convert to oral administration, which is more convenient for the patient, but only after titrating the dose parenterally.