Ease and Efficacy of Subcutaneous Ketamine for Depression in Home Hospice Patients: 2 Case Reports

Document Type

Conference Proceeding

Publication Date

5-1-2024

Publication Title

J Pain Symptom Manage

Abstract

Outcomes: 1. Identify hospice patients that would benefit from the use of ketamine in the home setting. 2. List the acceptable routes of administration and starting dose of Ketamine.

Key Message: Patients suffering from depression at the end of life often do not have weeks to wait for antidepressants to take effect. Ketamine is a promising treatment as it offers rapid and durable response; however, often requires infusion in a clinic or inpatient setting. These two cases demonstrate the safety and feasibility of administering subcutaneous ketamine in the home hospice setting.

Background: Ketamine is known to relieve treatment-resistant depression and opioid refractory pain. While antidepressants take several weeks, ketamine has a rapid onset, making it a promising therapy for depression in patients at end of life (EOL). Literature demonstrates that cancer patients may experience rapid and sustained improvement in depression and anxiety. These studies largely use compounded oral or intravenous (IV) formulations of ketamine which are barriers to widespread implementation. Hospices may not have access to compounding pharmacies and the IV route may not be feasible for patients at EOL, especially in the home setting.

Case Description: Mrs. C was an 80-year-old female with metastatic cervical cancer, severe pulmonary hypertension, and depression. She experienced severe major depression after home hospice enrollment. She was administered intravenous ketamine 0.5 mg/kg over 40 minutes in her home under physician and nurse supervision. She experienced rapid improvement in mood within an hour and no significant side effects or changes in vital signs. Her son stated, “I got my mom back.” Due to difficulty obtaining IV access two subsequent infusions were administered subcutaneously (SQ) over 45 minutes on weeks 2 and 3 following the initial. Effects on mood were sustained for the following 20 weeks until death. In case #2, Mrs. B was a 74-year-old female with congestive heart failure and depression. Her depression was poorly controlled on five agents. Subcutaneous ketamine was administered at the same dose and supervision as the first case while rotating her oral antidepressant regimen. She did not experience improvement in mood, but tolerated the injection without significant side effect or change in vital signs.

Conclusion: These cases suggest SQ ketamine administration is safe and feasible in the home hospice setting. Treatment response was mixed and highlights need for further research in dosing intervals and titration for apparent ketamine non-responders.

Volume

67

Issue

5

First Page

e623

Last Page

e624

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