The intravenous ketamine test predicts subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients.
Fibromyalgia (FM) is a challenging pain syndrome for which no reliable pharmacologic treatment exists. Recent clinical studies suggest that N-methyl-D-aspartate receptors might play a role in the pathogenesis of this disorder. To determine whether an intravenous (IV) ketamine test predicts the response to a therapeutic trial with an oral N-methyl-D-aspartate receptor antagonist, we performed a low-dose (0.1 mg/kg) IV ketamine infusion on 34 consecutive patients with FM, which was subsequently followed by an oral dextromethorphan (DX) treatment regimen. As per previous guidelines, the cutoff value for a positive response to the IV ketamine test was designated to be 67% pain relief, and a positive response to DX treatment was 50% pain reduction at 4- to 6-week follow-up visits. The degree of correlation between pain relief with ketamine and DX was highly significant (Pearson correlation coefficient, 0.66; P < .001). Ten patients responded positively to both ketamine and DX, 19 responded to neither drug, 3 had a positive response to ketamine but not DX, and 2 obtained good pain relief with DX but not ketamine. The sensitivity of the IV ketamine test was 83%, the specificity was 86%, the positive predictive value was 77%, and the negative predictive value was 91%. An association was also found between the development of side effects to the two treatments.


CONCLUSIONS
The response to an IV ketamine infusion was found to predict the subsequent response to an oral dextromethorphan treatment regimen in fibromyalgia patients, with an observed agreement of 83%. Considering the refractory nature of fibromyalgia to conventional pain treatments, the IV ketamine test might enhance patient care by saving time and reducing unnecessary treatment trials.
Cohen
Steven P
SP
Pain Management Division, Department of Anesthesiology & Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA. scohen40@jhmi.edu
Verdolin
Michael H
MH
Chang
Audrey S
AS
Kurihara
Connie
C
Morlando
Bennie J
BJ
Mao
Jianren
J
D000284:Administration, Oral; D000328:Adult; D000368:Aged; D000701:Analgesics, Opioid / Q000008:administration & dosage; D000778:Anesthetics, Dissociative / Q000008:administration & dosage; D003915:Dextromethorphan / Q000008:administration & dosage*; D004351:Drug Resistance / Q000187:drug effects* / Q000502:physiology; D004359:Drug Therapy, Combination; D018691:Excitatory Amino Acid Antagonists / Q000494:pharmacology; D005260:Female; D005356:Fibromyalgia / Q000188:drug therapy*; D006801:Humans; D007275:Injections, Intravenous; D007649:Ketamine / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement / Q000187:drug effects* / Q000379:methods*; D011237:Predictive Value of Tests; D016194:Receptors, N-Methyl-D-Aspartate / Q000037:antagonists & inhibitors / Q000378:metabolism; D016896:Treatment Outcome
D000701:Analgesics, Opioid; D000778:Anesthetics, Dissociative; D018691:Excitatory Amino Acid Antagonists; D016194:Receptors, N-Methyl-D-Aspartate; D007649:Ketamine; D003915:Dextromethorphan