Paired Medications
Because ketamine often results in a dissociative effect on the body, patients might feel some “normal” side effects such as anxiety, nausea, and increased blood pressure. Various medications may be used before or during a ketamine treatment in order to mitigate or eliminate these side effects. Below is a high-level review of common medications that could be paired with a ketamine treatment and is not intended to represent an exhaustive list or identify medication contraindications. It is important for patients to communicate their feelings, questions, symptoms, and concerns to the ketamine provider so that they can offer options to reduce discomfort and increase the likelihood of a good therapeutic effect.
Anxiety
Patients with general anxiety disorder might feel heightened anxiety before starting a ketamine infusion. Ketamine therapy for depression is relatively new and different to most patients. Therefore, there is an element of the unknown, which can result in increased anxiety and symptoms related to anxiety, such as worry, restlessness, difficulty sleeping the night before a treatment, fatigue, difficulty concentrating, irritability, increased heart rate, increase in body temperature, shortness of breath, or feelings of impending doom.
Patients who do not have a history of general anxiety disorder might still experience anxiety surrounding ketamine treatment, possibly due to unclear expectations or anecdotal stories of recreational ketamine use and/or bad “trips.” It is normal to feel uneasy and anxious when starting ketamine therapy. The best way to combat these feelings is through an open dialogue with the ketamine provider because they can help set the expectations and, if appropriate, provide medication in advance of the session to lessen any symptoms.
Providers use different approaches when it comes to medicating anxiety dependent on the needs of the patient and treatment approach. Some providers will medicate anxiety prior to ketamine treatment. Common medications include Xanax, lorazepam (Ativan), diazepam (Valium), midazolam (Versed), dexmedetomidine (Precedex), and magnesium. For patients treated using ketamine assisted psychotherapy (a.k.a. KAP), providers will assess whether medication is needed based on the therapeutic process and treatment goals. Patients are encouraged to speak with their provider about how they operate when it comes to anxiety.
Nausea
Nausea and vomiting are common side effects of ketamine, and in some cases, patients will be prescribed a medication, such as ondansetron (Zofran) or promethazine (Phenergan) or metoclopramide (Reglan), to take at home or in the waiting room prior to the start of a ketamine infusion. Propofol can sometimes be administered for severe intractable nausea and vomiting. Other medications such as scopolamine can also be helpful for patients with motion sickness or vertigo. It is important for patients to understand that dehydration can also cause nausea and to stay hydrated the day prior to and morning of a ketamine treatment.
High Blood Pressure
Clinicians closely monitor patient vital signs before and during the ketamine infusion, and elevated blood pressure is one of the few contraindications for ketamine treatment (i.e. make ketamine treatment inadvisable). This is because ketamine increases blood pressure and heart rate such that these readings are measured and monitored throughout a patient’s ketamine treatment for safety. That said, patients who are not prehypertensive or hypertensive, might still arrive at the clinic with increased blood pressure due to anxiety or other factors. Similar to pre-treatment for nausea, providers might prescribe an oral medication, such as clonidine (Catapres) for use prior to the ketamine infusion. Sometimes blood pressure readings during the infusion warrant medication intervention. In such cases, clinicians may treat the patient with labetalol (a beta blocker) or dexmedetomidine (Precedex).