IV Ketamine for Epilepsy

Recruiting in Palo Alto (17 mi)

Overseen by Lara Marcuse, MD

Age: 18+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Phase 2

Recruiting

Sponsor: Madeline Fields

Must be taking: Anti-seizure medications

Must not be taking: Psychostimulants, MAO inhibitors

Disqualifiers: Pregnancy, Cardiovascular disease, Schizophrenia, others

No Placebo Group

Prior Safety Data

Approved in 3 Jurisdictions

Trial Summary

What is the purpose of this trial?

This trial is testing small doses of ketamine to help people with epilepsy who don't respond to regular medications. Ketamine can help calm the brain and reduce seizures. The study will monitor patients' seizure activity and mood over time. Ketamine has been used in various settings for its ability to reduce seizures.

Do I have to stop taking my current medications for the trial?

You can continue taking your current anti-seizure medications as long as the doses have been stable for 12 weeks before starting the trial. However, if you are on psychostimulants or certain antidepressants (Monoamine oxidase inhibitors), you will need to stop those.

What data supports the effectiveness of the drug Ketamine Hydrochloride for epilepsy?

Research shows that ketamine, often used for anesthesia, has been effective in managing seizures in cases of refractory status epilepticus (a severe, prolonged seizure) in children, helping to avoid the need for intubation (inserting a tube into the airway). Additionally, low-dose IV ketamine has been used successfully in a patient with drug-resistant epilepsy to manage seizures without causing excessive sedation. ^{1 2 3 4 5}

Is IV ketamine generally safe for humans?

Ketamine is generally used safely in humans, but it can cause neuropsychiatric side effects like hallucinations and nightmares in some people. In studies, about 29% of patients experienced these effects, and 15% had to stop treatment because of them. Further research is needed to understand how to prevent these side effects. ^{2 3 5 6 7}

How is the drug ketamine unique in treating epilepsy?

Ketamine is unique for epilepsy treatment because it is used in low doses intravenously (through a vein) to manage seizures in patients who do not respond to other medications, and it can be transitioned to an oral form to reduce hospital stay. Unlike typical epilepsy drugs, ketamine works by blocking a specific brain receptor (N-methyl-D-aspartate) and helps avoid oversedation and the need for breathing support. ^{3 8 9 10 11}

Research Team

Madeline Fields, MD

Principal Investigator

Icahn School of Medicine

Lara Marcuse, MD

Principal Investigator

Icahn School of Medicine

Eligibility Criteria

This trial is for adults with drug-resistant epilepsy, having more than four seizures per month. They must have a stable use of seizure devices and anti-seizure medications for specific periods before the study starts. Excluded are pregnant or breastfeeding women, those at risk of suicide or homicide, with unstable illnesses, under 18 years old, substance misuse history within two years, certain cardiovascular conditions, immobility issues or recent severe seizures.

Inclusion Criteria

My cognitive impairment does not exclude me from this study.

Provision of signed and dated informed consent form

My epilepsy hasn't improved after trying two different medications.

Exclusion Criteria

I have had a severe seizure lasting minutes to hours within the last 3 months.

I am unable to walk and use a wheelchair or stay in bed.

Unstable medical illness

Trial Timeline

Screening

Participants are screened for eligibility to participate in the trial

4 weeks

Seizure diary filled, baseline mood assessment

Treatment

Participants receive 0.5mg/kg Racemic ketamine IV over 40 min three times a week for 2 consecutive weeks

2 weeks

6 visits (in-person)

Post-Treatment

Post-infusion safety assessments and post-treatment assessments including seizure diary collection and mood assessments

14 weeks

5 safety assessments (in-person), 3 assessments (phone calls)

Treatment Details

Interventions

• Ketamine Hydrochloride (NMDA Receptor Antagonist)

Trial Overview The trial tests if low doses of IV Ketamine can help control seizures in outpatients with epilepsy that doesn't respond to standard drugs. It's exploring whether this approach used in hospitals for continuous seizures can be effective when patients aren't hospitalized.

Participant Groups

Group I: IV Ketamine Hydrochloride Experimental Treatment 1 Intervention

dose 0.5mg/kg of IV Ketamine Hydrochloride over 40 min

Ketamine Hydrochloride is already approved in Canada for the following indications:

Approved in Canada as Ketamine Hydrochloride for:

• Anesthesia
• Pain management
• Depression

Who Is Running the Clinical Trial?

Madeline Fields

Lead Sponsor

Trials

1

Recruited

9+

Findings from Research

Intravenous ketamine dosing for procedural sedation in children varies by age, with recommended single bolus doses of 1.5 to 2.125 mg/kg, but larger doses can lead to deeper sedation and slower recovery times.

Using a smaller initial dose followed by a 'top-up' or continuous infusion can achieve the desired sedation level more effectively, with quicker recovery times, highlighting the importance of tailoring doses based on individual patient needs and the type of pain management required.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Dosing ketamine for pediatric procedural sedation in the emergency department. Dallimore, D., Herd, DW., Short, T., et al.[2022]

Ketamine hydrochloride (50mg/ml) remains chemically stable for up to 180 days when stored in polypropylene syringes at room temperature, making it suitable for advance preparation.

The study confirmed that the concentration of ketamine does not fall below 90% of its initial value during this period, ensuring its efficacy for use as an anesthetic agent.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Long-term stability of ketamine hydrochloride 50mg/ml injection in 3ml syringes. Huvelle, S., Godet, M., Hecq, JD., et al.[2022]

Low-dose intravenous ketamine can be effectively used in patients with drug-resistant epilepsy to manage seizures without causing oversedation, as demonstrated in a clinical case where it helped avoid intubation.

The study highlights the potential for transitioning from IV ketamine to an oral formulation, which may reduce hospital stay duration and suggests the need for personalized dosing based on pharmacogenomic factors.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ketamine in seizure management and future pharmacogenomic considerations. Borsato, GS., Siegel, JL., Rose, MQ., et al.[2021]

Intravenous ketamine has been shown to be effective in treating refractory convulsive status epilepticus (RCSE) in children, resolving 14 out of 19 episodes in a study involving 13 patients aged 2 months to 11 years.

Ketamine offers a significant advantage by potentially avoiding endotracheal intubation, which can worsen the prognosis of RCSE, as it was used successfully in 5 patients as an alternative to conventional anesthetics.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Ketamine in refractory convulsive status epilepticus in children avoids endotracheal intubation. Ilvento, L., Rosati, A., Marini, C., et al.[2018]

In a study involving 9 children with refractory convulsive status epilepticus (RSE), intravenous ketamine was found to be effective in resolving RSE in 6 of the patients, demonstrating its potential as a treatment option.

The treatment was deemed safe, as none of the patients experienced serious adverse events, suggesting that ketamine could be a viable alternative for children who do not respond to conventional anesthetics.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Efficacy and safety of ketamine in refractory status epilepticus in children. Rosati, A., L'Erario, M., Ilvento, L., et al.[2022]

In a study of 58 patients with refractory status epilepticus (RSE), intravenous ketamine achieved permanent control of seizures in 57% of episodes, indicating its potential efficacy as a treatment option.

The mortality rate was significantly lower (16%) when RSE was controlled within 24 hours of starting ketamine, suggesting that timely intervention with ketamine may improve outcomes in patients with RSE.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study. Gaspard, N., Foreman, B., Judd, LM., et al.[2022]

In a study of 171 hospitalized patients receiving low-dose ketamine for pain management, 29.2% experienced neuropsychiatric adverse effects, with 15.2% needing to discontinue treatment due to these effects.

The study found no significant differences in the likelihood of experiencing adverse effects between patients who tolerated ketamine and those who did not, suggesting that predicting these effects is challenging; further research is needed to explore the potential role of benzodiazepines in mitigating these adverse effects.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Risk Factors for the Development of Neuropsychiatric Adverse Effects in Ketamine-Treated Pain. Quirk, K., Smith, MA.[2022]

In a study involving mice, ketamine at a sub-effective dose did not enhance the pain-relieving (antinociceptive) effects of benzodiazepines like diazepam, chlordiazepoxide, and clonazepam, indicating a lack of interaction between these drugs.

Ketamine alone was effective in protecting against seizures induced by pentetrazole, but it did not change the anticonvulsant effects of the benzodiazepines, suggesting that combining these medications may not provide additional benefits in pain relief or seizure protection.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Lack of interaction between the behavioral effects of ketamine and benzodiazepines in mice. Fidecka, S., Pirogowicz, E.[2013]

In a study involving nine children with medically intractable epilepsy, high-dose intravenous levetiracetam (IV-LEV) at doses averaging 228 mg/kg/day effectively resolved acute repetitive seizures in eight out of nine patients.

IV-LEV was well tolerated with no significant complications, and seven children experienced a reduction in seizure frequency, indicating its potential as a safe and effective treatment for acute seizure exacerbations.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

High-dose intravenous levetiracetam for acute seizure exacerbation in children with intractable epilepsy. Depositario-Cabacar, DT., Peters, JM., Pong, AW., et al.[2018]

In a study of 229 pediatric patients, intravenous (IV) ketamine administration led to a quicker discharge time from the emergency department compared to intramuscular (IM) ketamine, with a difference of 21 minutes from drug administration to discharge.

The overall rate of adverse events was lower in the IV group (20%) compared to the IM group (35%), suggesting that IV ketamine may have a better safety profile in this context.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration. Ramaswamy, P., Babl, FE., Deasy, C., et al.[2022]

References

1. United States pubmed.ncbi.nlm.nih.gov

Dosing ketamine for pediatric procedural sedation in the emergency department. [2022]

2. France pubmed.ncbi.nlm.nih.gov

Long-term stability of ketamine hydrochloride 50mg/ml injection in 3ml syringes. [2022]

3. United States pubmed.ncbi.nlm.nih.gov

Ketamine in seizure management and future pharmacogenomic considerations. [2021]

4. United States pubmed.ncbi.nlm.nih.gov

Ketamine in refractory convulsive status epilepticus in children avoids endotracheal intubation. [2018]

5. United States pubmed.ncbi.nlm.nih.gov

Efficacy and safety of ketamine in refractory status epilepticus in children. [2022]

6. United States pubmed.ncbi.nlm.nih.gov

Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study. [2022]

7. England pubmed.ncbi.nlm.nih.gov

Risk Factors for the Development of Neuropsychiatric Adverse Effects in Ketamine-Treated Pain. [2022]

8. Poland pubmed.ncbi.nlm.nih.gov

Lack of interaction between the behavioral effects of ketamine and benzodiazepines in mice. [2013]

9. England pubmed.ncbi.nlm.nih.gov

Intravenous ketamine plus midazolam is superior to intranasal midazolam for emergency paediatric procedural sedation. [2019]

10. United States pubmed.ncbi.nlm.nih.gov

High-dose intravenous levetiracetam for acute seizure exacerbation in children with intractable epilepsy. [2018]

11. United States pubmed.ncbi.nlm.nih.gov

Pediatric procedural sedation with ketamine: time to discharge after intramuscular versus intravenous administration. [2022]