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Correspondence to Dr Agnès Calsina-Berna, Palliative Care Service. Research and knowledge group in palliative care of Catalan Institute of Oncology (GRICOPAL), Institut Català d'Oncologia-Badalona, Badalona, Spain; [email protected]
Introduction
The increasing prevalence of cancer survivors has heightened the importance of adequate cancer pain management over extended periods.1
Opioids are used as first-line therapy for neuropathic cancer pain. One of the most important causes of decreasing opioid responsiveness is N-methyl-D-aspartate (NMDA) overactivity. In this context other medications can be needed to achieve proper analgesia.
Ketamine is an anaesthetic agent with analgesic properties, mainly due to its antagonism in the NMDA receptor. In 1990s, the first reports of subanaesthetic uses of ketamine were described for cancer pain relief, with low doses showing efficacy.
To date, there have been no reports of long-term ketamine oral use in the management of chronic neuropathic cancer pain. Herein, we present the management of a young patient with sarcoma and neuropathic pain who received oral ketamine as a co-analgesic for months.
Case presentation
A 42-year-old man presented with persistent pain leading to a diagnosis of myxoid liposarcoma in the left buttock in 2017 requiring partial excision. He was admitted at the Palliative Care Unit for uncontrolled cancer pain due to local progression of the disease after two lines of chemotherapy. The patient was on transdermal fentanyl at a dose of 75 mg/hour over 72 hours and gabapentin as a coanalgesic. He reported severe pain in the left buttock that radiated to the leg, with perineal hypoesthesia. He was started on morphine intravenous, requiring rapid titration. Dexamethasone and gabapentin were added for improving baseline pain control. Rescue doses (PRN) of subcutaneous (SC) morphine were also effective.
Invasive anaesthetic techniques were declined by the patient due to the risk of losing functional capacity and ambulation. He agreed to radiotherapy as analgesic modality. He was discharged home on oral morphine (180 mg every 12 hours), SC morphine 10 mg PRN (10 mg was effective, and the patient preferred low doses to avoid side effects), dexamethasone, gabapentin and naproxen as co-analgesics.
While under palliative care outpatient follow-up, several months later the pain worsened due to local disease progression, and it was...