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Ketamine therapy:
the second visit
 Briefing: previous report
Patient 0 experience
Update of KT on treating tinnitus
 What is ketamine??

❖ Analgesics
❖ Dissociative hallucination
❖ Psychedelic assisted therapy
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How it works?
Ketamine helps patient being sensitive to
psychological therapy

Psychological therapy: meditation,

aroma+music, CBT, even virtual reality
therapy
 Mechanism of action

❖ 1. NMDA receptor inhibitor->

decrease GABA release
❖ 2. Decrease GABA release->
increase presynaptic glutamate
release
❖ 3. Increase postsynaptic
plasticity
 Ketamine therapy in psychiatry

❖ Low dose ketamine therapy-> safe, minimal respiratory suppression,

low risk of addiction
❖ FDA approved for refractory MMD, GAD, PTSD
❖ Trial: migraine, phantom pain, chronic pain, chronic tinnitus,
insomnia[disorders of synaptic malplasticity]
 Racemic -ketamine Esketamine

Ingredients R-ketamine+S-ketamine S-ketamine

4x more potent NMDA

Pharmacology
inhibitor

Low addiction in medical

Addiction Less addiction?
setting

Analgesics in hospital Nasal spray, 台灣已上市,

Cost
setting ⾃費
 Ketamine therapy in Taiwan
❖ 2017 TPVGH research: ketamine therapy on refractory
MMD, GAD
❖ 2022 esketamine approved in Taiwan, well response rate:
50% v.s. 75%(USA)
 Patient selection

❖ Chronic tinnitus+ refractory GAD/MMD or refractory

VM/CM or refractory primary insomnia
❖ Chronic tinnitus only
 Diagnosis:
**typical CVM+GAD c/w panic
disorders+ secondary insomnia

Patient 0 experience i. Cochlear symptoms: chronic

tinnitus for >5 years, persistent
and loud(initial VAS 8-10/10),
no notable SNHL

ii. Vestibular symptoms:

refractory MAD, major vertigo
attacks: frequent(>1time/month)
 Pre-KT treatment

❖ Patient intolerant to SSRI due to uncontrollable ADR

❖ Refractory VCM: still frequent, debilitating despite trokendi #2,
uzine#2, Harkin 1# BID
❖ Severe insomnia: zolpidem 1#+neuroquel 1#+ clonazepam 2#
fl
 KT therapy protocol
❖ Drugs to avoid day before KT: a.
BZD b. SSRI, SNRI c. beta-
blocker, CCB d. Ritalin e. Alcohol
❖ Mid-night NPO
❖ Dosage: 0.5-1mg/kg, 500ml NS,
1-1.5hr IV pump, primperan
1#PRN, vena 1# PRN
❖ CBT, environment optimization
❖ 治療後先休息30分鐘，治療後當
天不開⾞
 First KT therapy

❖ Pre-KT preparation: CBT, environment

optimization
❖ Key points: eye blinds, ⽿罩式⽿機, meditating
music, aroma[好的精油 不可蝦⽪貨]
❖ Outcome: success!! Immediate improvement on
migraine, mood, tinnitus, dizziness
 Second KT therapy

❖ Pre-KT: no CBT, no optimization

❖ 環境: 超⾳波室 noisy, stinky, interrupting, no music,
no aroma
❖ Outcome: failure, GAD worsen, tinnitus louder
 Updates

❖ Randomized control, prospective

❖ Chronic tinnitus w/wo GAD,MMD
❖ Variables: THI, VASm depression scale, glutamate/GABA
ratio
 Prospects

❖ Recruit more patients with CVM+refractory GAD

❖ Establish ef cacy of KT therapy
❖ KT therapy with VR+ tDCS or rTMS
fi