Can Targin (oxycodone/naloxone) be given with ketamine?

Targin (Oxycodone/Naloxone) and Ketamine Combination Therapy

Yes, Targin (oxycodone/naloxone) can be safely administered with ketamine, but careful monitoring is required due to potential respiratory effects when combining these medications.

Pharmacological Considerations

Mechanism of Action

• Targin: Fixed 2:1 ratio combination of prolonged-release oxycodone (opioid analgesic) with naloxone (opioid antagonist) 1

  • Naloxone has low bioavailability when administered orally, acting primarily in the gut to reduce opioid-induced constipation
  • Oxycodone provides systemic analgesia

• Ketamine: NMDA receptor antagonist with analgesic and sedative properties 2

  • Rapid onset (1 minute IV) and short duration (10-15 minutes) 3
  • Unlike opioids, ketamine generally preserves respiratory drive and airway reflexes at standard doses 2

Safety Profile of the Combination

Advantages

• Ketamine can provide additional analgesia through a different mechanism than opioids 4
• The combination may allow for lower doses of each medication, potentially reducing side effects 5
• Ketamine preserves airway reflexes better than benzodiazepine/opioid combinations 2

Potential Concerns

1. Cardiovascular Effects:

   • Ketamine produces dose-dependent increases in heart rate, blood pressure, and cardiac output 2
   • Should be avoided in patients with ischemic heart disease, cerebrovascular disease, or hypertension 3, 2

2. Neuropsychiatric Effects:

   • Emergence reactions (floating sensations, vivid dreams, hallucinations) occur in 10-30% of adults 3, 2
   • Consider adding midazolam to mitigate these effects 3, 2

Monitoring Requirements

When administering this combination:

• Continuous monitoring of vital signs is essential 2
• Have naloxone readily available for reversal of opioid-induced respiratory depression 3
• Monitor for:
  • Respiratory depression
  • Oxygen desaturation
  • Changes in blood pressure and heart rate
  • Emergence reactions

Dosing Considerations

• Ketamine:

  • Start with lower doses when combining with opioids
  • IV: 0.1-0.5 mg/kg titrated to effect 6
  • IM: 1-2 mg/kg if IV access unavailable 3

• Targin:

  • Continue prescribed dosing regimen
  • Consider whether dose adjustment is needed when adding ketamine

Clinical Applications

This combination may be particularly useful for:

1. Procedural sedation and analgesia 3
2. Management of severe acute pain 4
3. Patients with opioid tolerance 2
4. Patients with opioid-induced constipation requiring analgesia 1

Contraindications

Absolute contraindications to this combination:

• Severe respiratory depression
• Ischemic heart disease
• Uncontrolled hypertension
• Cerebrovascular disease
• Known hypersensitivity to either agent

Risk Mitigation Strategies

1. Use the minimum effective dose of both medications
2. Consider adding midazolam to reduce emergence reactions from ketamine
3. Ensure appropriate monitoring equipment is available
4. Have resuscitation equipment readily accessible
5. Titrate ketamine carefully, especially in elderly patients or those with underlying medical conditions 2

This combination can be effective for pain management while potentially reducing opioid requirements, but requires careful patient selection and monitoring to ensure safety.