• Elodie Martin, Marc Sorel, Véronique Morel, Fabienne Marcaillou, Pascale Picard, Noémie Delage, Florence Tiberghien, Marie-Christine Crosmary, Mitra Najjar, Renato Colamarino, Christelle Créach, Béatrice Lietar, Géraldine Brumauld de Montgazon, Anne Margot-Duclot, Marie-Anne Loriot, Céline Narjoz, Céline Lambert, Bruno Pereira, and Gisèle Pickering.
• Université Clermont Auvergne, Pharmacologie Fondamentale Et Clinique de la Douleur, Neuro-Dol, Inserm 1107, F-63000 Clermont-Ferrand, France.
• Drug Des Dev Ther. 2019 Jan 1; 13: 2677-2688.

PurposeIntravenous ketamine is often prescribed in severe neuropathic pain. Oral N-methyl-D-aspartate receptor (NMDAR) antagonists might prolong pain relief, reducing the frequency of ketamine infusions and hospital admissions. This clinical trial aimed at assessing whether oral dextromethorphan or memantine might prolong pain relief after intravenous ketamine.Patients And MethodsA multicenter randomized controlled clinical trial included 60 patients after ketamine infusion for refractory neuropathic pain. Dextromethorphan (90 mg/day), memantine (20 mg/day) or placebo was given for 12 weeks (n=20 each) after ketamine infusion. The primary endpoint was pain intensity at one month. Secondary endpoints included pain, sleep, anxiety, depression, cognitive function and quality of life evaluations up to 12 weeks.ResultsAt 1 month, dextromethorphan maintained ketamine pain relief (Numeric Pain Scale: 4.01±1.87 to 4.05±2.61, p=0.53) and diminished pain paroxysms (p=0.03) while pain intensity increased significantly with memantine and placebo (p=0.04). At 3 months, pain remained lower than at inclusion (p=0.001) and was not significantly different in the three groups. Significant benefits were observed on cognitive-affective domains and quality of life for dextromethorphan and memantine (p<0.05).ConclusionsOral dextromethorphan given after ketamine infusion extends pain relief during one month and could help patients to better cope with pain. Future studies should include larger populations stratified on pharmacogenetics screening. Optimization of an oral drug that could extend ketamine antihyperalgesia, with fewer hospital admissions, remains a prime challenge in refractory neuropathic pain.

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