Consensus Guidelines for the Use of Intravenous Ketamine for Chronic Pain

A panel of experts formulated consensus guidelines for physicians who use intravenous ketamine infusions to treat chronic pain, which were published in Regional Anesthesia and Pain Medicine.

The Ketamine Guidelines Committee, which included representatives from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists, collaborated to assess past clinical studies and database findings in order to answer several essential questions regarding ketamine infusion including:

1. Which patients and pain conditions should be considered?

2. What are the contraindications?

3. Is there any evidence that a therapeutic dose cutoff threshold, a dose-response relationship, longer/more frequent infusions, or higher dosages is more effective?

4. Is there any role for oral ketamine or another N-methyl-D-aspartate receptor antagonist as a follow-up to infusion?

5. Should there be pre-infusion testing requirements?

6. What training should be required for personnel administering and monitoring treatment?

7. What preemptive medications should be available in case of adverse effects?

8. What constitutes a positive response in chronic pain?

The committee introduced recommendations in response to each question. Overall, they came to the consensus that evidence supports the use of ketamine for chronic pain, but the quality of evidence differs between conditions and dose ranges. In addition, although serious adverse effects associated with ketamine infusions are rare, higher dosages and more frequent infusions are usually associated with greater risk.

While these guidelines are based on comprehensive research and expertise, panel members noted that most studies examined were small and uncontrolled. Thus, they concluded, “Larger studies, evaluating a wider variety of conditions, are needed to better quantify efficacy, improve patient selection, refine the therapeutic dose range, determine the effectiveness of non-intravenous ketamine alternatives, and develop a greater understanding of the long-term risks of repeated treatments.”

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Reference

Cohen S, et al. Consensus guidelines on the use of intravenous ketamine infusions for chronic pain from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, and the American Society of Anesthesiologists [published online July 2018]. Regional Anesthesia and Pain Medicine. doi: 10.1097/AAP. 0000000000000808