Department of Psychiatry, University of Alberta, Edmonton, AB, Canada.
Misericordia Community Hospital, Edmonton, AB, Canada.
CNS Drugs. 2022 Mar;36(3):239-251. doi: 10.1007/s40263-022-00897-2. Epub 2022 Feb 14.
Intravenous (IV) ketamine is increasingly used off-label at subanesthetic doses for its rapid antidepressant effect, and intranasal (IN) esketamine has been recently approved in several countries for treating depression. The clinical utility of these treatments is limited by a paucity of publicly funded IV ketamine and IN esketamine programs and cost barriers to private treatment programs, as well as the drug cost for IN esketamine itself, which makes generic ketamine alternatives an attractive option. Though evidence is limited, use of non-parenteral racemic ketamine formulations (oral, sublingual, and IN) may offer more realistic access in less rigidly supervised settings, both for acute and maintenance treatment in select cases. However, the psychiatric literature has repeatedly cautioned on the addictive potential of ketamine and raised caution for both less supervised and longer-term use of ketamine. To date, these concerns have not been discussed in view of available evidence, nor have they been discussed within a broader clinical context. This paper examines the available relevant literature and suggests that ketamine misuse risks appear not dissimilar to those of other well-established and commonly prescribed agents with abuse potential, such as stimulants or benzodiazepines. As such, ketamine prescribing should be considered in a similar risk/benefit context to balance patient access and need for treatment with concern for potential substance misuse. Our consortium of mood disorder specialists with significant ketamine prescribing experience considers prescribing of non-parenteral ketamine a reasonable clinical treatment option in select cases of treatment-resistant depression. This paper outlines where this may be appropriate and makes practical recommendations for clinicians in judicious prescribing of non-parenteral ketamine.
静脉注射（IV）氯胺酮因其快速抗抑郁作用而越来越多地被超适应证用于亚麻醉剂量，鼻内（IN）依他佐辛也已在多个国家获得批准用于治疗抑郁症。这些治疗方法的临床应用受到公共资助 IV 氯胺酮和 IN 依他佐辛计划缺乏以及私人治疗计划的成本障碍的限制，以及 IN 依他佐辛本身的药物成本限制，这使得非专利氯胺酮替代品成为一个有吸引力的选择。尽管证据有限，但使用非注射用外消旋氯胺酮制剂（口服、舌下和 IN）可能在监管不太严格的环境下提供更现实的途径，无论是在特定情况下进行急性治疗还是维持治疗。然而，精神科文献一再警告氯胺酮的成瘾潜力，并对氯胺酮的监管较少和长期使用提出警告。迄今为止，鉴于现有证据，尚未对此类问题进行讨论，也未在更广泛的临床背景下进行讨论。本文研究了现有相关文献，并认为氯胺酮滥用的风险似乎与其他具有滥用潜力的既定和常用药物（如兴奋剂或苯二氮䓬类药物）相似。因此，应根据风险/效益情况考虑氯胺酮的处方问题，以平衡患者接受治疗的需求与对潜在药物滥用的关注。我们的心境障碍专家联盟具有丰富的氯胺酮处方经验，认为在某些治疗抵抗性抑郁症病例中，非注射用氯胺酮的处方是合理的临床治疗选择。本文概述了在哪些情况下可能适用，并为临床医生明智地开具非注射用氯胺酮提出了实用建议。
