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La ketamina en el tratamiento del dolor crónico según medicina basada en la evidencia
| Content Provider | Semantic Scholar |
|---|---|
| Author | Reina, Fernando Neira García, J. Luisa Ortega |
| Copyright Year | 2016 |
| Abstract | espanolLa ketamina es un antagonista no competitivo de los receptores NMDA y tiene un amplio mecanismo de accion que involucra, ademas, a los receptores AMPA, kainato, acido gamma-aminobutirico, opioides, monoaminergicos, muscarinicos y nicotinicos. Actua sobre los canales de calcio y sodio voltaje-dependientes, interviene en la sintesis y liberacion del oxido nitrico e inhibe la recaptacion de serotonina. La interaccion con todos estos mecanismos de accion hace que tenga una importante participacion sobre mecanismos del dolor, inflamacion, neuroproteccion y tolerancia de opioides. En este trabajo se revisan las diferentes vias de administracion de la ketamina, su dosificacion, las modalidades de administracion, la duracion del tratamiento, las indicaciones segun los niveles de evidencia disponibles y los efectos secundarios; para establecer su eficacia en la terapeutica del dolor cronico y promover un tratamiento mas especifico, en aquellas patologias en las que se ha demostrado una mayor eficacia. Se realizo una busqueda en Trip Database Population Intervention Comparison Outcome (PICO), National Guidelines Clearinghouse, Cochrane Library, Medline, CMA infobase, Health Services/Technology Assessment, New Zealand Guidelines Group y Scottish Intercollegiate Guidelines Network. La ketamina tiene una gran versatilidad en cuanto a sus vias de administracion (intravenosa, intramuscular, subcutanea, sublingual, oral, rectal, nasal, transdermica, epidural y subaracnoidea), asi como modalidades de administracion (bolos, infusion continua). No obstante, la via oral es la mas utilizada y preferida para el tratamiento del dolor cronico. Sin embargo, no disponemos de una formulacion oral comercializada, lo que dificulta su utilizacion. El empleo clinico de la ketamina requiere una cuidadosa seleccion del paciente y valoracion de la relacion riesgo/beneficio. Se debe tener presente los antecedentes de abuso de drogas ante el riesgo potencial de abuso del farmaco. Se dispone de evidencia sobre la eficacia de la ketamina en pacientes con dolor oncologico refractario y en el sindrome doloroso regional complejo (SDRC). Hay evidencia moderada sobre la eficacia de la ketamina intravenosa a dosis bajas, en el SDRC, que no justifica su utilizacion sistematica en este sindrome. En el dolor neuropatico, la ketamina se ha mostrado especialmente eficaz en el control de la alodinia, hiperalgesia e hiperpatia, pero existen controversias sobre su utilizacion. La ketamina oral puede tener un lugar en el tratamiento del dolor cronico de los pacientes refractarios a tratamientos habituales. Se ha mostrado util como coadyuvante de otros analgesicos, especialmente en pacientes en tratamiento con opioides, permitiendo disminuir la dosis e incrementando el control analgesico de los pacientes con dolor cronico. EnglishKetamine is a noncompetitive NMDA receptor antagonist and has a large action's mechanism, that involves receptors: AMPA, kainate, gamma-aminobutyric acid, opioids, monoamine, muscarinic and nicotinic. It is acting on voltage-dependent calcium channels, join in the synthesis and release of nitric oxide and inhibits serotonin reuptake. The interaction with these mechanisms of action makes it an important role on mechanisms of pain, inflammation, neuroprotection and opioid tolerance. In this paper we review the different routes of administration of ketamine, dosage, modes of administration, duration of treatment, indications according to levels of evidence available and side effects to set up its efficacy in the therapy of chronic pain and promote a more specific treatment, in those pathologies where it has shown greater efficacy. We perform a search in: Trip Database Population Intervention Comparison Outcome (PICO), National Guidelines Clearinghouse, Cochrane Library, Medline, CMA infobase, Health Services/Technology Assessment, New Zealand Guidelines Group and Scottish Intercollegiate Guidelines Network. Ketamine is very versatile in their routes of administration: intravenous, intramuscular, subcutaneous, sublingual, oral, rectal, nasal, transdermic, epidural and subarachnoid; as well as their ways of administration (bolus, continuous infusion). However, the oral route is the most widely used and preferred for the treatment of chronic pain. However, we do not have an oral formulation marketed, making it difficult to use. Clinical use of ketamine requires careful patient's selection and assessment of the risk/benefit ratio. Ketamine has a potential risk of drug abuse; therefore, it should checked prior history of drug abuse. It is available evidence on the efficacy of ketamine in patients with refractory cancer pain and complex regional pain syndrome (CRPS). The use of low-dose intravenous ketamine has moderate evidence in CRPS, that does not justify its routine use in this syndrome. In neuropathic pain, ketamine has been particularly effective in controlling allodynia, hyperalgesia and hyperpathia, although there is controversy over its use. Oral ketamine may have a place in the treatment of chronic pain patients refractory to standard treatments. It is shown useful as an adjuvant to other analgesics, especially in patients treated with opioids, allowing reduction of doses and increasing pain relief in patients with chronic pain. |
| Starting Page | 292 |
| Ending Page | 306 |
| Page Count | 15 |
| File Format | PDF HTM / HTML |
| DOI | 10.20986/resed.2016.3462/2016 |
| Volume Number | 23 |
| Alternate Webpage(s) | http://scielo.isciii.es/pdf/dolor/v23n6/revision_mbe.pdf |
| Alternate Webpage(s) | http://gestoreditorial.resed.es/DOI/PDF/ArticuloDOI_3462.pdf |
| Alternate Webpage(s) | https://doi.org/10.20986/resed.2016.3462%2F2016 |
| Language | English |
| Access Restriction | Open |
| Content Type | Text |
| Resource Type | Article |
