The Efficacy of a Subanesthetic Doses of IV Ketamine in the Treatment Drug Resistant Epilepsy

Drug Resistant Epilepsy Clinical Trial

Official title:

A Pilot Study to Assess the Efficacy of Subanesthetic Doses of IV Ketamine in the Treatment Drug Resistant Epilepsy

Clinical Trial Details — Status: Recruiting

Administrative data

• NCT number: NCT05019885
• Other study ID #: STUDY-20-01911
• Status: Recruiting
• Phase: Phase 2
• Start date: August 26, 2022
• Est. completion date: December 2024

Study information

• Verified date: June 2024
• Source: Icahn School of Medicine at Mount Sinai
• Contact: Onome Eka, MBBS MPH
• Phone: 212-241-8861
• Email: onome.eka[@]mssm.edu
• Is FDA regulated: No
• Study type: Interventional

Clinical Trial Summary

Ketamine is a medication that came into clinical practice in the 1960's. Ketamine is used as an anesthetic and to provide pain relief. Recently, Ketamine was approved to treat drug resistant depression using subanesthetic doses. In the hospital setting, intravenous anesthetic dosages are used to treat unrelenting seizures known as status epilepticus in comatose patients. Ketamine in subanesthetic doses has not been tried as a treatment for medication resistant seizures in the outpatient setting. This study would like to examine the effectiveness of subanesthetic ketamine in outpatients who suffer from drug resistant epilepsy.

Description:

This is an open label pilot study that will evaluate the effectiveness of a sub-anaesthetic dose (0.5mg/kg) of IV Ketamine in Drug Resistant Epilepsy Patients. Mood assessments will also be administered. The study consists of 3 phases:

Screening : Seizure diary will be prospectively filled for 4 weeks and subjects must have at least 4 seizures in 28 days to proceed to the treatment phase. Baseline mood assessment will be performed (NDDI-E, QOLIE-10, GAD 7 )

Treatment Phase: This phase will consist of 6 study visits (3 visits/ week for 2 weeks). Patients will receive 0.5mg/kg Racemic ketamine IV over 40 min three times a week (M, W, F) for 2 consecutive weeks.

Treatment Visit 1: Monday Week 5(baseline seizures diary collected) Treatment Visit 2:

Wednesday Week 5 Treatment Visit 3: Friday Week 5 Treatment Visit 4: Monday Week 6 Treatment Visit 5: Wednesday Week 6 Treatment Visit 6: Friday Week 6 (Mood assessments performed prior to infusion)

Post- Treatment Phase : This phase will consist of 5 post infusion safety assessments and 3 post-treatment assessments.

Post-Infusion Safety Assessment 1: Saturday Week 6 (Adverse Event Assessment) Post-Infusion Safety Assessment 2: Sunday Week 7 (Adverse Event Assessment) Post-Infusion Safety Assessment 3: Monday Week 7 (Adverse Event Assessment) Post-Infusion Safety Assessment 4: Monday Week 8 (Adverse Event Assessment) Post-Infusion Safety Assessment 5: Monday Week 9 (Adverse Event Assessment)

Post-Treatment Assessment 1: phone call week 10 (Seizure diary collection, mood assessments performed) Post-Treatment Assessment 2: phone call week 14 (Seizure diary) Post-Treatment Assessment 3: phone call week 18 (Seizure diary collection, mood assessments performed)

Recruitment information / eligibility

• Status: Recruiting
• Enrollment: 8
• Est. completion date: December 2024
• Est. primary completion date: December 2024
• Accepts healthy volunteers: No
• Gender: All
• Age group: 18 Years and older

Eligibility

Inclusion Criteria:

• Provision of signed and dated informed consent form

• Adults (18 years or older)

• Cognitively impaired adults are not excluded (i.e. will be included in the study)

• Established diagnosis of Drug Resistant Epilepsy (DRE) i.e. failed two or more appropriately chosen anti-seizure medications (ASMs)

• EEG consistent with focal or generalized epilepsy

• Patients must have >4 focal aware, focal impaired aware, focal to bilateral tonic clonic or generalized tonic clonic seizures per month.

• Patients can be on >/= 1 anti-seizure medication (ASM) at the time of enrollment on stable doses 12 weeks prior to initiation

• Patients on Epilepsy devices: Vagal nerve stimulator (VNS), Deep brain stimulator (DBS) or Responsive Nerve Stimulator (RNS) must have remained stable for at least 4 weeks before the screening visit. Adjustment of devices is not allowed during the study.

Exclusion Criteria

• Patients <18 years of age

• Pregnant women

• Women that are breast feeding

• Patients who had >21 days of seizure freedom in the last year.

• Patients with a history of status epilepticus within 3 months of screening

• Patients with a history of alcoholism of drug misuse within the last 2 years

• Unstable medical illness

• Serious or imminent suicidal or homicidal risk

• Patients with cardiovascular disease

• Patients with schizophrenia

• Patients with history of aneurysm or aortic dissection, arteriovenous malformation and intracerebral hemorrhage

• Patients that are immobile i.e. wheel chair bound, bed ridden individuals

• Patients on psychostimulants (amphetamines, methylphenidate etc.) and Monoamine oxidase inhibitors (selegiline, isocarboxazid, phenelzine etc.)

Related Conditions & MeSH terms

• Drug Resistant Epilepsy
• Epilepsy
• Refractory Epilepsy

Intervention

Drug:
• Ketamine Hydrochloride
Three times a week (M, W, F) for 2 consecutive weeks.

Locations

Country	Name	City	State
United States	Mount Sinai Hospital	New York	New York

Sponsors (1)

Lead Sponsor	Collaborator
Madeline Fields

Country where clinical trial is conducted

United States, 

References & Publications (37)

aan het Rot M, Collins KA, Murrough JW, Perez AM, Reich DL, Charney DS, Mathew SJ. Safety and efficacy of repeated-dose intravenous ketamine for treatment-resistant depression. Biol Psychiatry. 2010 Jan 15;67(2):139-45. doi: 10.1016/j.biopsych.2009.08.038. — View Citation

Aram JA, Martin D, Tomczyk M, Zeman S, Millar J, Pohler G, Lodge D. Neocortical epileptogenesis in vitro: studies with N-methyl-D-aspartate, phencyclidine, sigma and dextromethorphan receptor ligands. J Pharmacol Exp Ther. 1989 Jan;248(1):320-8. — View Citation

Berman RM, Cappiello A, Anand A, Oren DA, Heninger GR, Charney DS, Krystal JH. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry. 2000 Feb 15;47(4):351-4. doi: 10.1016/s0006-3223(99)00230-9. — View Citation

Brodie MJ. Road to refractory epilepsy: the Glasgow story. Epilepsia. 2013 May;54 Suppl 2:5-8. doi: 10.1111/epi.12175. — View Citation

Dingledine R, Borges K, Bowie D, Traynelis SF. The glutamate receptor ion channels. Pharmacol Rev. 1999 Mar;51(1):7-61. No abstract available. — View Citation

Esaian D, Joset D, Lazarovits C, Dugan PC, Fridman D. Ketamine continuous infusion for refractory status epilepticus in a patient with anticonvulsant hypersensitivity syndrome. Ann Pharmacother. 2013 Nov;47(11):1569-76. doi: 10.1177/1060028013505427. Epub 2013 Oct 9. — View Citation

Feder A, Parides MK, Murrough JW, Perez AM, Morgan JE, Saxena S, Kirkwood K, Aan Het Rot M, Lapidus KA, Wan LB, Iosifescu D, Charney DS. Efficacy of intravenous ketamine for treatment of chronic posttraumatic stress disorder: a randomized clinical trial. JAMA Psychiatry. 2014 Jun;71(6):681-8. doi: 10.1001/jamapsychiatry.2014.62. — View Citation

Fujikawa DG. Neuroprotective effect of ketamine administered after status epilepticus onset. Epilepsia. 1995 Feb;36(2):186-95. doi: 10.1111/j.1528-1157.1995.tb00979.x. — View Citation

Gaspard N, Foreman B, Judd LM, Brenton JN, Nathan BR, McCoy BM, Al-Otaibi A, Kilbride R, Fernandez IS, Mendoza L, Samuel S, Zakaria A, Kalamangalam GP, Legros B, Szaflarski JP, Loddenkemper T, Hahn CD, Goodkin HP, Claassen J, Hirsch LJ, Laroche SM. Intravenous ketamine for the treatment of refractory status epilepticus: a retrospective multicenter study. Epilepsia. 2013 Aug;54(8):1498-503. doi: 10.1111/epi.12247. Epub 2013 Jun 12. — View Citation

Hsieh CY, Sung PS, Tsai JJ, Huang CW. Terminating prolonged refractory status epilepticus using ketamine. Clin Neuropharmacol. 2010 May;33(3):165-7. doi: 10.1097/WNF.0b013e3181d1e3cd. — View Citation

Kramer AH. Early ketamine to treat refractory status epilepticus. Neurocrit Care. 2012 Apr;16(2):299-305. doi: 10.1007/s12028-011-9668-7. — View Citation

Kramer U, Shorer Z, Ben-Zeev B, Lerman-Sagie T, Goldberg-Stern H, Lahat E. Severe refractory status epilepticus owing to presumed encephalitis. J Child Neurol. 2005 Mar;20(3):184-7. doi: 10.1177/08830738050200030301. — View Citation

Kwan P, Arzimanoglou A, Berg AT, Brodie MJ, Allen Hauser W, Mathern G, Moshe SL, Perucca E, Wiebe S, French J. Definition of drug resistant epilepsy: consensus proposal by the ad hoc Task Force of the ILAE Commission on Therapeutic Strategies. Epilepsia. 2010 Jun;51(6):1069-77. doi: 10.1111/j.1528-1167.2009.02397.x. Epub 2009 Nov 3. Erratum In: Epilepsia. 2010 Sep;51(9):1922. — View Citation

Lang E, Mallien AS, Vasilescu AN, Hefter D, Luoni A, Riva MA, Borgwardt S, Sprengel R, Lang UE, Gass P, Inta D. Molecular and cellular dissection of NMDA receptor subtypes as antidepressant targets. Neurosci Biobehav Rev. 2018 Jan;84:352-358. doi: 10.1016/j.neubiorev.2017.08.012. Epub 2017 Aug 23. — View Citation

Lapidus KA, Levitch CF, Perez AM, Brallier JW, Parides MK, Soleimani L, Feder A, Iosifescu DV, Charney DS, Murrough JW. A randomized controlled trial of intranasal ketamine in major depressive disorder. Biol Psychiatry. 2014 Dec 15;76(12):970-6. doi: 10.1016/j.biopsych.2014.03.026. Epub 2014 Apr 3. — View Citation

Lawn ND, Bamlet WR, Radhakrishnan K, O'Brien PC, So EL. Injuries due to seizures in persons with epilepsy: a population-based study. Neurology. 2004 Nov 9;63(9):1565-70. doi: 10.1212/01.wnl.0000142991.14507.b5. — View Citation

Lent JK, Arredondo A, Pugh MA, Austin PN. Ketamine and Treatment-Resistant Depression. AANA J. 2019 Oct;87(5):411-419. — View Citation

Mazarati AM, Wasterlain CG. N-methyl-D-asparate receptor antagonists abolish the maintenance phase of self-sustaining status epilepticus in rat. Neurosci Lett. 1999 Apr 23;265(3):187-90. doi: 10.1016/s0304-3940(99)00238-4. — View Citation

McCagh J, Fisk JE, Baker GA. Epilepsy, psychosocial and cognitive functioning. Epilepsy Res. 2009 Sep;86(1):1-14. doi: 10.1016/j.eplepsyres.2009.04.007. Epub 2009 Jul 18. — View Citation

Mewasingh LD, Sekhara T, Aeby A, Christiaens FJ, Dan B. Oral ketamine in paediatric non-convulsive status epilepticus. Seizure. 2003 Oct;12(7):483-9. doi: 10.1016/s1059-1311(03)00028-1. — View Citation

Mohanraj R, Norrie J, Stephen LJ, Kelly K, Hitiris N, Brodie MJ. Mortality in adults with newly diagnosed and chronic epilepsy: a retrospective comparative study. Lancet Neurol. 2006 Jun;5(6):481-7. doi: 10.1016/S1474-4422(06)70448-3. — View Citation

Murrough JW, Burdick KE, Levitch CF, Perez AM, Brallier JW, Chang LC, Foulkes A, Charney DS, Mathew SJ, Iosifescu DV. Neurocognitive effects of ketamine and association with antidepressant response in individuals with treatment-resistant depression: a randomized controlled trial. Neuropsychopharmacology. 2015 Mar 13;40(5):1084-90. doi: 10.1038/npp.2014.298. — View Citation

Murrough JW, Iosifescu DV, Chang LC, Al Jurdi RK, Green CE, Perez AM, Iqbal S, Pillemer S, Foulkes A, Shah A, Charney DS, Mathew SJ. Antidepressant efficacy of ketamine in treatment-resistant major depression: a two-site randomized controlled trial. Am J Psychiatry. 2013 Oct;170(10):1134-42. doi: 10.1176/appi.ajp.2013.13030392. — View Citation

Murrough JW, Perez AM, Pillemer S, Stern J, Parides MK, aan het Rot M, Collins KA, Mathew SJ, Charney DS, Iosifescu DV. Rapid and longer-term antidepressant effects of repeated ketamine infusions in treatment-resistant major depression. Biol Psychiatry. 2013 Aug 15;74(4):250-6. doi: 10.1016/j.biopsych.2012.06.022. Epub 2012 Jul 27. — View Citation

Niciu MJ, Ionescu DF, Richards EM, Zarate CA Jr. Glutamate and its receptors in the pathophysiology and treatment of major depressive disorder. J Neural Transm (Vienna). 2014 Aug;121(8):907-24. doi: 10.1007/s00702-013-1130-x. Epub 2013 Dec 8. — View Citation

Pruss H, Holtkamp M. Ketamine successfully terminates malignant status epilepticus. Epilepsy Res. 2008 Dec;82(2-3):219-22. doi: 10.1016/j.eplepsyres.2008.08.005. Epub 2008 Sep 19. — View Citation

Rosati A, De Masi S, Guerrini R. Ketamine for Refractory Status Epilepticus: A Systematic Review. CNS Drugs. 2018 Nov;32(11):997-1009. doi: 10.1007/s40263-018-0569-6. — View Citation

Scott AJ, Sharpe L, Hunt C, Gandy M. Anxiety and depressive disorders in people with epilepsy: A meta-analysis. Epilepsia. 2017 Jun;58(6):973-982. doi: 10.1111/epi.13769. Epub 2017 May 3. — View Citation

Sheth RD, Gidal BE. Refractory status epilepticus: response to ketamine. Neurology. 1998 Dec;51(6):1765-6. doi: 10.1212/wnl.51.6.1765. No abstract available. — View Citation

Synowiec AS, Singh DS, Yenugadhati V, Valeriano JP, Schramke CJ, Kelly KM. Ketamine use in the treatment of refractory status epilepticus. Epilepsy Res. 2013 Jul;105(1-2):183-8. doi: 10.1016/j.eplepsyres.2013.01.007. Epub 2013 Jan 29. — View Citation

Tarocco A, Ballardini E, Garani G. Use of ketamine in a newborn with refractory status epilepticus: a case report. Pediatr Neurol. 2014 Jul;51(1):154-6. doi: 10.1016/j.pediatrneurol.2014.03.006. Epub 2014 Mar 15. — View Citation

Ubogu EE, Sagar SM, Lerner AJ, Maddux BN, Suarez JI, Werz MA. Ketamine for refractory status epilepticus: a case of possible ketamine-induced neurotoxicity. Epilepsy Behav. 2003 Feb;4(1):70-5. doi: 10.1016/s1525-5050(02)00643-1. — View Citation

Walker MC, Howard RS, Smith SJ, Miller DH, Shorvon SD, Hirsch NP. Diagnosis and treatment of status epilepticus on a neurological intensive care unit. QJM. 1996 Dec;89(12):913-20. doi: 10.1093/qjmed/89.12.913. — View Citation

Yeh PS, Shen HN, Chen TY. Oral ketamine controlled refractory nonconvulsive status epilepticus in an elderly patient. Seizure. 2011 Nov;20(9):723-6. doi: 10.1016/j.seizure.2011.06.001. Epub 2011 Jul 2. — View Citation

Zarate CA Jr, Singh JB, Carlson PJ, Brutsche NE, Ameli R, Luckenbaugh DA, Charney DS, Manji HK. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry. 2006 Aug;63(8):856-64. doi: 10.1001/archpsyc.63.8.856. — View Citation

Zeiler FA, Kaufmann AM, Gillman LM, West M, Silvaggio J. Ketamine for medically refractory status epilepticus after elective aneurysm clipping. Neurocrit Care. 2013 Aug;19(1):119-24. doi: 10.1007/s12028-013-9858-6. — View Citation

Zeiler FA, Teitelbaum J, Gillman LM, West M. NMDA antagonists for refractory seizures. Neurocrit Care. 2014 Jun;20(3):502-13. doi: 10.1007/s12028-013-9939-6. — View Citation

* Note: There are 37 references in all — Click here to view all references

Outcome

Type	Measure	Description	Time frame	Safety issue
Primary	Number of participants with seizure reduction	50% seizure reduction during the 2 week period of active treatment	2 week during active treatment
Primary	Number of participants with seizure reduction	50% seizure reduction during the 28 days post-infusion.	28 days post infusion
Primary	Seizure frequency	Return to pre-ketamine infusion seizure frequency in 3 months	3 months post infusion
Secondary	Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) Score	The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is a 6-item questionnaire validated to screen for depression in people with epilepsy. Scores range from 6 - 24, with higher scores indicating more depressive symptoms.	Week 6
Secondary	Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) Score	The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is a 6-item questionnaire validated to screen for depression in people with epilepsy. Scores range from 6 - 24, with higher scores indicating more depressive symptoms.	Week 10
Secondary	Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) Score	The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is a 6-item questionnaire validated to screen for depression in people with epilepsy. Scores range from 6 - 24, with higher scores indicating more depressive symptoms.	Week 14
Secondary	Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) Score	The Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) is a 6-item questionnaire validated to screen for depression in people with epilepsy. Scores range from 6 - 24, with higher scores indicating more depressive symptoms.	Week 18
Secondary	Quality of Life in Epilepsy (QOLIE-10)	Quality of Life in Epilepsy (QOLIE)-10 scale is a validated, reliable instrument measuring quality of life on a scale from 10-51, lower score indicates better health outcome.	Week 6
Secondary	Quality of Life in Epilepsy (QOLIE-10)	Quality of Life in Epilepsy (QOLIE)-10 scale is a validated, reliable instrument measuring quality of life on a scale from 10-51, lower score indicates better health outcome.	Week 10
Secondary	Quality of Life in Epilepsy (QOLIE-10)	Quality of Life in Epilepsy (QOLIE)-10 scale is a validated, reliable instrument measuring quality of life on a scale from 10-51, lower score indicates better health outcome.	Week 14
Secondary	Quality of Life in Epilepsy (QOLIE-10)	Quality of Life in Epilepsy (QOLIE)-10 scale is a validated, reliable instrument measuring quality of life on a scale from 10-51, lower score indicates better health outcome.	Week 18
Secondary	General Anxiety Disorder 7-item questionnaire (GAD-7)	The General Anxiety Disorder 7-item questionnaire (GAD-7) is a 7-item questionnaire that asks user to rank how often they have been bothered by seven problems over the past two weeks from "0" (not at all) to "3" (nearly every day). The items that users are asked to rank levels of nervousness, anxiousness, relaxing, restlessness, irritability and fearfulness. Full scale from 0-21, with higher score indicating more symptoms.	week 6
Secondary	General Anxiety Disorder 7-item questionnaire (GAD-7)	The General Anxiety Disorder 7-item questionnaire (GAD-7) is a 7-item questionnaire that asks user to rank how often they have been bothered by seven problems over the past two weeks from "0" (not at all) to "3" (nearly every day). The items that users are asked to rank levels of nervousness, anxiousness, relaxing, restlessness, irritability and fearfulness. Full scale from 0-21, with higher score indicating more symptoms.	week 10
Secondary	General Anxiety Disorder 7-item questionnaire (GAD-7)	The General Anxiety Disorder 7-item questionnaire (GAD-7) is a 7-item questionnaire that asks user to rank how often they have been bothered by seven problems over the past two weeks from "0" (not at all) to "3" (nearly every day). The items that users are asked to rank levels of nervousness, anxiousness, relaxing, restlessness, irritability and fearfulness. Full scale from 0-21, with higher score indicating more symptoms.	week 14
Secondary	General Anxiety Disorder 7-item questionnaire (GAD-7)	The General Anxiety Disorder 7-item questionnaire (GAD-7) is a 7-item questionnaire that asks user to rank how often they have been bothered by seven problems over the past two weeks from "0" (not at all) to "3" (nearly every day). The items that users are asked to rank levels of nervousness, anxiousness, relaxing, restlessness, irritability and fearfulness. Full scale from 0-21, with higher score indicating more symptoms.	week 18