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Intranasal (NAS) Ketamine for Cancer Pain

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ClinicalTrials.gov Identifier: NCT03146806
Recruitment Status : Recruiting
First Posted : May 10, 2017
Last Update Posted : November 20, 2018
Sponsor:
Information provided by (Responsible Party):
Vinita Singh, Emory University

Brief Summary:
The main purpose of this study is to determine the safety, feasibility, and utility of intranasal (NAS) ketamine in persistent uncontrolled cancer related pain. In this prospective clinical trial the researchers will investigate the use of NAS ketamine in patients with pain related to cancer or cancer treatment. The researchers plan to enroll at least 25 patients meeting inclusion/exclusion criteria, to achieve a minimum of 10 patients who complete the study. Participants will be recruited from the supportive oncology clinic, oncology clinics, the pain clinic and Acute Pain Service at Emory. Participants will be asked to return to the Phase I unit of the Winship Cancer Building C for a total of 5 study visits, each two to five days apart. During these visits participants will complete questionnaires, have blood samples drawn and will have study medication administered to them in escalating doses. For safety monitoring participants will be contacted by telephone 14 days after the last dose of medication administered.

Condition or disease Intervention/treatment Phase
Cancer Pain Drug: Intranasal ketamine Phase 1 Phase 2

Detailed Description:

There are about 11.9 million Americans affected with cancer. 53% of patients with cancer experience pain at all stages of cancer. These patients often require high doses of opioids with uncontrolled pain that makes them too sedated to effectively participate in day-to-day activities and have a good quality of life. Depression often co-exists with cancer pain due to the nature of the disease. The researchers are searching for improved therapies for chronic cancer pain and ketamine with its novel mechanism of action may be a promising solution.

Ketamine is an FDA approved anesthetic with the ability to effect memory loss, pain relief and sedation. Safety and efficacy of ketamine as an anesthetic and analgesic agent is well documented. Low doses of ketamine have minimal adverse impact on circulatory or breathing functions but can reduce pain. Research has shown that ketamine is effective in controlling breakthrough pain and reducing depression in a randomized double blind controlled trial. There is limited data regarding the use of ketamine for pain management in cancer.

One of the challenges with ketamine is the route of administration, most commonly given intravenously (IV) or intramuscularly (IM). It has also been given by mouth and rectally, but absorption is very poor. Intranasal (NAS) administration may be a promising method of delivery and can be ordered by a physician from a compounding pharmacy. From other research the investigators expect absorption to be higher than oral or rectal administration and this method of delivery as needle-free is a patient-friendly route of administration.

The main purpose of this study is to determine the safety, feasibility, and utility of intranasal (NAS) ketamine in persistent uncontrolled cancer related pain. In this prospective clinical trial the researchers will investigate the use of NAS ketamine in patients with pain related to cancer or cancer treatment. The researchers plan to enroll at least 15 patients meeting inclusion/exclusion criteria, to achieve a minimum of 10 patients who complete the study. Participants will be recruited from the oncology clinic, pain clinic and Acute Pain Service at Emory. Participants will be asked to return to the Phase I unit of the Winship Cancer Building C for a total of 5 study visits, each two to five days apart. During these visits participants will complete questionnaires, have blood samples drawn and will have study medication administered to them in escalating doses. For safety monitoring participants will be contacted by telephone 14 days after the last dose of medication administered.

Data obtained from this study will help determine if ketamine provides a reduction of pain using the Numeric Pain Rating Scale and a reduction in the use of opioid consumption and other rescue medications. Additionally the researchers will study the bioavailability, pharmacodynamics and pharmacokinetics of ketamine and the safety profile of NAS ketamine.


Study Type : Interventional  (Clinical Trial)
Estimated Enrollment : 25 participants
Intervention Model: Single Group Assignment
Masking: None (Open Label)
Primary Purpose: Supportive Care
Official Title: Safety of Intranasal Ketamine for Reducing Uncontrolled Cancer Related Pain
Actual Study Start Date : July 25, 2017
Estimated Primary Completion Date : June 1, 2019
Estimated Study Completion Date : October 1, 2019

Resource links provided by the National Library of Medicine

Drug Information available for: Ketamine

Arm Intervention/treatment
Experimental: Intranasal ketamine treatment
Study participants who are receiving intranasal ketamine treatments.
Drug: Intranasal ketamine

10mg of intranasal ketamine will be given to make sure that the study patients are able to tolerate a small dose of NAS ketamine.

On the second visit, 10 mg of IV ketamine will be given to help establish bioavailability of NAS ketamine, with patients serving as their own controls.

On the third and fourth visit, higher doses of ketamine, 30 mg and 50 mg respectively, will be given.

All doses of ketamine will be administered by an anesthesia research nurse.

Other Names:
  • NAS ketamine
  • Ketamine hydrochloride (HCl) intranasal




Primary Outcome Measures :
  1. Bioavailability of intranasal (NAS) ketamine [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Blood samples will be obtained at the study visits to measure the bioavailability (a pharmacokinetic characteristic) of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. Study visits will occur every 2 to 5 days. Samples will be obtained 2, 30, 60 and 240 minutes after medication administration on visits 1 through 4. Baseline samples will be obtained at visits 2-5.

  2. Peak concentration (Cmax) of intranasal (NAS) ketamine [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Blood samples will be obtained at the study visits to measure the peak concentration (Cmax) (a pharmacokinetic characteristic) of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. Study visits will occur every 2 to 5 days. Samples will be obtained 2, 30, 60 and 240 minutes after medication administration on visits 1 through 4. Baseline samples will be obtained at visits 2-5.

  3. Elimination of intranasal (NAS) ketamine [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Blood samples will be obtained at the study visits to measure elimination (a pharmacokinetic characteristic) of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. Study visits will occur every 2 to 5 days. Samples will be obtained 2, 30, 60 and 240 minutes after medication administration on visits 1 through 4. Baseline samples will be obtained at visits 2-5.

  4. Time to peak concentration (Tmax) of intranasal (NAS) ketamine [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Blood samples will be obtained at the study visits to measure time to peak concentration (a pharmacokinetic characteristic) of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. Study visits will occur every 2 to 5 days. Samples will be obtained 2, 30, 60 and 240 minutes after medication administration on visits 1 through 4. Baseline samples will be obtained at visits 2-5.

  5. Half life of intranasal (NAS) ketamine [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Blood samples will be obtained at the study visits to measure the half life (a pharmacokinetic characteristic) of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. Study visits will occur every 2 to 5 days. Samples will be obtained 2, 30, 60 and 240 minutes after medication administration on visits 1 through 4. Baseline samples will be obtained at visits 2-5.

  6. Clearance of intranasal (NAS) ketamine [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Blood samples will be obtained at the study visits to measure clearance (a pharmacokinetic characteristic) of NAS ketamine through analysis of ketamine and its metabolite norketamine to determine pharmacokinetic properties. Study visits will occur every 2 to 5 days. Samples will be obtained 2, 30, 60 and 240 minutes after medication administration on visits 1 through 4. Baseline samples will be obtained at visits 2-5.

  7. Change in Numerical Pain Rating Scale (NPRS) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported pain scores, participants will complete the Numerical Pain Rating Scale (NPRS). Pain scores will be recorded on NPRS prior to and at 5,10,15, 30, 45, 60, 120, and 180 and 240 minutes after administration of test medication. The NPRS has participants rate their current level of pain intensity on a scale from 0 (no pain) to 10 (worst possible pain). In general, improvements of pain severity </=1.5 points on NPRS could be seen as clinically irrelevant. Above that value, the cutoff point for "clinical relevance" depends on patients' baseline pain severity, and ranges from 2.4 to 5.3. Higher baseline scores require larger raw changes to represent clinically important differences.

  8. Change in fatigue assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any fatigue and will indicate the severity of this side effect by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  9. Change in dizziness assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any dizziness, and will indicate the severity of this side effect by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  10. Change in nausea assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any nausea and will indicate the severity of this side effect by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  11. Change in headache assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing a headache and will indicate the severity of this side effect by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  12. Change in feeling of unreality assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]

    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5.

    Participants will be asked if they are experiencing any feeling of unreality and will indicate the severity of this side effect by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).


  13. Change in hearing assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any changes in hearing and will indicate the severity of side effects by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  14. Change in vision assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any changes in vision and will indicate the severity of side effects by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  15. Change in mood assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any changes in mood and will indicate the severity of side effects by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  16. Change in general discomfort assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any changes in general discomfort and will indicate the severity of side effects by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  17. Change in hallucinations assessed by Side Effect Rating Scale for Dissociative Anesthetics (SERSDA) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    To evaluate patient reported side effects, participants will complete the Side Effect Rating Scale for Dissociative Anesthetics (SERSDA). During visits 1 - 4, side effects will be documented by SERSDA prior to administration of medication and 30, 60 and 240 minutes after medication is given. The SERSDA will be administered upon arrival for study visit 5. Participants will be asked if they are experiencing any changes in hallucination and will indicate the severity of side effects by selecting 0 (no change), 1 (weak), 2 (modest), 3 (bothersome), or 4 (very bothersome).

  18. Change in Montgomery Asberg Depression Rating Scale (MADRS) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    Depression will be assessed on the Montgomery Asberg Depression Rating Scale (MADRS) on each visit. This is a depression rating scale designed to be particularly sensitive to treatment effects. The MADRS is a 10-item scale where the survey administrator rates the participant on a variety of aspects related to depression (such as apparent sadness, tension, and pessimistic thoughts) based on a clinical interview. Responses are on a scale of 0 to 6 where 0 signifies no difficulties in this area and 6 signifies severe difficulty. Total scores range from 0 to 60 with higher scores indicating greater severity of depression. The questionnaire will be administered to patients, if screened positive for depression, before medication administration and again between 180 and 240 minutes after medication given.

  19. Change in Edmonton Symptom Assessment System (ESAS) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    The Edmonton Symptom Assessment System (ESAS) assessing nine symptoms common in cancer patients: pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being and shortness of breath. ESAS score will be obtained prior to providing the study medication at each visit. The scales range from 0 (absence of symptom) to 10 (worst possible degree of symptom) and total scores range from 1 to 90, with higher scores indicating greater severity of all symptoms.

  20. Change in Eastern Cooperative Oncology Group (ECOG) score [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    The Eastern Cooperative Oncology Group (ECOG) score evaluates performance status of the participants by rating their ability to perform physical tasks and self care. Responses are 0 (fully active), 1 (restricted in physical strenuous activity but ambulatory), 2 (ambulatory and capable of all self-care but unable to carry out work activities), 3 (capable of only limited self-care), 4 (completely disabled), or 5 (dead). ECOG score will be obtained prior to providing the study medication at each visit.

  21. Change in Patient-Reported Outcomes Measurement Information System (PROMIS) scales [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    The PROMIS v.1.1-Global consists of 10 items that assess general domains of health and functioning. The scoring system of the PROMIS v.1.1-Global allows each of the individual items to be examined separately to gain information about perceptions of physical, mental, and social health, and general perceptions of health. Respondents rate their level of a variety of aspects of health on a scale of 1 to 5 and rate their level of pain between 0 and 10. Responses to some questions are re-coded so that higher scores reflect better functioning.


Secondary Outcome Measures :
  1. Frequency of rescue medication use [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    The opioid sparing effect of NAS ketamine will be determined by evaluating frequency of rescue medications use prior to and during the study. Georgia prescription monitoring database will be searched by the investigators and an opioid pill count will be done at each visit to monitor opioid intake during the study. Documentation of rescue medication taken and interval of opioid intake (usual or longer) will be done.

  2. Total opioid consumption [ Time Frame: Visit 1 (Baseline) through Visit 5 (up to 20 days) ]
    The opioid sparing effect of NAS ketamine will be determined by evaluating total opioid consumption (rescue medication) prior to and during the study. Georgia prescription monitoring database will be searched by the investigators and an opioid pill count will be done at each visit to monitor opioid intake during the study.



Information from the National Library of Medicine

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the contacts provided below. For general information, Learn About Clinical Studies.


Ages Eligible for Study:   18 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No
Criteria

Inclusion Criteria:

  • Patients with uncontrolled pain related to cancer or cancer treatment. Uncontrolled pain will be defined as:

    • Pain which persists for more than 7 days and is rated >/=6 on Numerical Pain Rating Score (NPRS)
    • Use of breakthrough medication more than 4 times in 24 hours or being treated with oral morphine equivalent of 100 mg/d or more
  • Patients who are able to follow-up in person during the trial
  • Patient on stable analgesic regimen for >7 days without escalation during study period with rescue or immediate release medication every 3 hours or longer
  • Patients who are willing and able to maintain a daily pain diary
  • Patients who are able to understand written and verbal English
  • Patient weight >/= 50 kg

Exclusion Criteria:

  • Transportation issues interfering with return study visits
  • Patients with high disposition of laryngospasm or apnea
  • Presence of severe cardiac disease
  • Presence of conditions where significant elevations in blood pressure would be a serious hazard.
  • Stage 2 hypertension or greater (systolic blood pressure > 160 and/or diastolic blood pressure >100)
  • Baseline tachycardia, heart rate (HR) >100
  • History of seizures, elevated intracranial pressure (ICP) or cerebrospinal fluid (CSF) obstructive states (e.g. severe head injury, central congenital or mass lesions)
  • Conditions that may increase intraocular pressure (e.g. glaucoma, acute globe injury)
  • History of uncontrolled depression or other psychiatric comorbidity with psychosis
  • History of liver disease
  • History of interstitial cystitis
  • History of nasal or sinus anomalies or dysfunction e.g. allergic or infectious rhinitis.
  • Patients with lesions to the nasal mucosa
  • Pregnant women, nursing mothers and women of childbearing potential not using contraception known to be highly effective. Highly effective contraception methods include combination of any two of the following:

    • Use of oral, injected or implanted hormonal methods of contraception or;
    • Placement of an intrauterine device (IUD) or intrauterine system (IUS);
    • Barrier methods of contraception: condom or occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/ vaginal suppository;
    • Total abstinence or;
    • Male/female sterilization.
  • Illicit substance abuse within the past 6 months
  • Documented history of medication abuse/misuse (e.g. Unsanctioned dose escalation, broken opioid agreement etc.)
  • Clinical requirement for medications that are concurrent inducers or inhibitors of CYP3A4. CYP3A4 substrates are allowed.
  • Porphyria (possibility of triggering a porphyric reaction)
  • Severe active anemia ( a hemoglobin< 8 documented by labs drawn within 3 months of first study treatment)
  • History of difficult intravenous access
  • Intractable vomiting

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its ClinicalTrials.gov identifier (NCT number): NCT03146806


Contacts
Contact: Vinita Singh, MD 404-778-3900 vinita.singh@emory.edu

Locations
United States, Georgia
Winship Cancer Institute Recruiting
Atlanta, Georgia, United States, 30322
Contact: Vinita Singh, MD    404-778-3900    vinita.singh@emory.edu   
Sponsors and Collaborators
Emory University
Investigators
Principal Investigator: Vinita Singh, MD Emory University

Responsible Party: Vinita Singh, Assistant Professor, Emory University
ClinicalTrials.gov Identifier: NCT03146806     History of Changes
Other Study ID Numbers: IRB00086610
First Posted: May 10, 2017    Key Record Dates
Last Update Posted: November 20, 2018
Last Verified: November 2018
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: Undecided

Studies a U.S. FDA-regulated Drug Product: Yes
Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Vinita Singh, Emory University:
Cancer pain
Anesthesiology
Opiates
Intranasal ketamine

Additional relevant MeSH terms:
Cancer Pain
Pain
Neurologic Manifestations
Nervous System Diseases
Signs and Symptoms
Ketamine
Analgesics
Sensory System Agents
Peripheral Nervous System Agents
Physiological Effects of Drugs
Anesthetics, Dissociative
Anesthetics, Intravenous
Anesthetics, General
Anesthetics
Central Nervous System Depressants
Excitatory Amino Acid Antagonists
Excitatory Amino Acid Agents
Neurotransmitter Agents
Molecular Mechanisms of Pharmacological Action