II. Background

  1. Esketamine (Spravato) is an active isomer (s-entiomer) of racemic Ketamine used intranasally
  2. Nonselective, noncompetive glutamate receptor antagonist (at N-Methyl-D-Aspartate Receptor)
  3. C-III medication with abuse potential and requiring provider REMS enrollment

III. Indications

  1. Refractory Depression Management (adults)
    1. Adjunctive in combination with oral Antidepressants
  2. See Ketamine for other indications (analgesia, Anesthesia)
    1. Esketamine (Spravato) is not intended for use for analgesia or Anesthesia

IV. Contraindications

  1. Ketamine Hypersensitivity
  2. Aneurysmal vascular disease or other vascular abnormalities
    1. Thoracic Aortic Aneurysm
    2. Abdominal Aortic Aneurysm
    3. Intracranial Aneurysm
    4. Arteriovenous malformation
    5. Intracerebral Hemorrhage history

V. Dosing

  1. Used in combination with Antidepressants
  2. Esketamine (Spravato) is administered twice weekly for 4 weeks then once every 1-2 weeks
  3. Observe patient for 2 hours after each dose for Hypertension, sedation, dissociation
  4. Titrate over 1-9 weeks to maximum dose of 84 mg per week

VI. Adverse Effects

  1. See Ketamine
  2. Dissociative Reaction (altered cognition, judgment, attention)
  3. Anxiety
  4. Suicidality
  5. Dizziness or Vertigo
  6. Sedation or lethargy
  7. Nausea or Vomiting
  8. Hypoesthesia
  9. Hypertension
  10. Ketamine Abuse

VII. Precautions

  1. Expensive ($900/dose)
  2. Potential for Ketamine Abuse (hence the REMS program)
  3. Avoid in pregnancy

VIII. References

  1. (2019) Presc Lett 26(5)
  2. LoVecchio (2019) Crit Dec Emerg Med 33(6): 28

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