Title: Ketamine for Alcohol Withdrawal?<br/>Author: Bryan Hayes<br/><a href='http://umem.org/profiles/faculty/369/'>[Click to email author]</a><hr/><h3 dir="ltr" style="line-height: 1.38; margin-top: 14pt; margin-bottom: 0pt;">
<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-9b44d1c7-1abf-63fb-c9d1-09e51b15ece9"><span style="color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">Background </span></span></span></span></h3>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-9b44d1c7-1abf-63fb-c9d1-09e51b15ece9"><span style="color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">In addition to the down regulation of GABA receptors in chronic ethanol users, there is an upregulation in NMDA receptor subtypes. Although the pathophysiology is much more complex, when ethanol abstinence occurs, there is a shortage of GABA-mediated CNS inhibition and a surplus of glutamate-mediated CNS excitation. If GABA agonists are the mainstay of treatment, why not also target the NMDA receptor? Enter ketamine.</span></span></span></span></p>
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<span style="font-size:12px;"><span style="color: rgb(0, 0, 0); white-space: pre-wrap; font-family: arial, helvetica, sans-serif; line-height: 1.38; background-color: transparent;">The Data</span></span></h3>
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<span style="font-size:12px;"><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">Only one study exists and was published recently</span><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">. </span></span></p>
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<span style="font-size:12px;"><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">R</span><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap;">etrospective review of 23 adult patients administered ketamine specifically for management of AWS.</span></span></li>
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<span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; white-space: pre-wrap;">Mean time to initiation of ketamine from first treatment of AWS, and total duration of therapy were 33.6 and 55.8 hours, respectively.</span></li>
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<span style="font-size:12px;"><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap;">Mean initial infusion dose and median total infusion rate were 0.21 and 0.20 mg/kg/h, respectively.</span></span></li>
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<span style="font-size:12px;"><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap;">No change in sedation or alcohol withdrawal scores within 6 hours of ketamine initiation.</span></span></li>
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<span style="font-size:12px;"><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap;">Median change in benzodiazepine requirements at 12 and 24 hours post-ketamine initiation were -40.0 and -13.3 mg, respectively.</span></span></li>
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<span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; white-space: pre-wrap;">One documented adverse reaction of oversedation, requiring dose reduction.</span></li>
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<span style="font-size:12px;"><span style="font-family: arial, helvetica, sans-serif; line-height: 1.6199821472168; color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap;">Authors concluded that ketamine appears to reduce benzodiazepine requirements and is well tolerated at low doses. </span></span></li>
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<span style="font-size:12px;"><span style="font-family:arial,helvetica,sans-serif;"><span id="docs-internal-guid-9b44d1c7-1abf-63fb-c9d1-09e51b15ece9"><span style="color: rgb(0, 0, 0); vertical-align: baseline; white-space: pre-wrap; background-color: transparent;">Application to Clinical Practice</span></span></span></span></h3>
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<span style="color: rgb(0, 0, 0); white-space: pre-wrap; font-family: arial, helvetica, sans-serif; line-height: 1.38; background-color: transparent;">While the <a href="http://www.aliem.com/dexmedetomidine-precedex-as-an-adjunct-to-benzodiazepines-for-ethanol-withdrawal/">dexmedetomidine studies</a> should not be using reduction in benzodiazepine requirements as an endpoint, it may be acceptable for ketamine since it actually works on the underlying pathophysiology. More studies are needed but it's good to see we’re starting to look at it.</span></p>
<fieldset><legend>References</legend>
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Wong A, et al. Evaluation of adjunctive ketamine to benzodiazepines for management of alcohol withdrawal syndrome. <em>Ann Pharmacother </em>2015;49(1):14-9. [<a href="http://www.ncbi.nlm.nih.gov/pubmed/25325907">PMID 25325907</a>]</p>
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<strong>Follow me on Twitter (<a href="https://twitter.com/PharmERToxGuy">@PharmERToxGuy</a>) or Google Plus (+bryanhayes13)</strong></p>
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