Esketamine (US brand name Spravato™) is an antagonist of N-methyl D-aspartate (NMDA) receptors, which are one of the types of receptors to which the neurotransmitter glutamate binds. Here is some basic information about this medication. For more details, please see the pages linked to under Related Pages below.
What is esketamine?
Esketamine is an enantiomer of ketamine. Ketamine is a mixture of S-ketamine (or esketamine) and R-ketamine (or arketamine). The molecules of these two are identical in their chemical composition but are mirror images of each other. Ketamine has been available in the US since 1970 and is FDA-approved for use as a general anesthetic.
As noted above, esketamine blocks N-methyl D-aspartate (NMDA) receptors. R-ketamine does the same, but S-ketamine (esketamine) has a higher affinity for the NMDA receptor than R-ketamine.
(Optional to read: Esketamine is a “non-competitive” blocker of NMDA receptors. If you don’t know the significance of that, don’t worry. It is not important for clinicians.)
In recent years, there has been a realization that the pathophysiology of major depressive disorder does not only involve dysregulation of monoamine systems; impairments in neural connectivity are involved as well (Duman et al., 2016). Ketamine increases the release of brain-derived neurotrophic factor (BDNF), increases the formation of new synapses (synaptogenesis), and, so, improves structural connectivity in the brain.
Esketamine nasal spray was approved by the FDA in 2019.
Amazingly, this is what the wording of the FDA indication says:
“...indicated in conjunction with an oral antidepressant for the treatment of treatment-resistant depression in adults.”
I say “amazingly” because the wording of the indication :
– Doesn’t distinguish between various types of depressive disorders
– Uses the term “treatment-resistant” depression without defining what that means in this context.
But, don’t worry—on another page on this website, SPMH elaborates on these issues by going to the published research (see Related Pages below).
Please note that:
– It is approved not for monotherapy but for adjunctive use along with an oral antidepressant medication.
– It is approved for use in adults only
The image below shows the boxed warning from the full Prescribing Information for Spravato.
Potential side effects
Coming soon for Members only…along with a handout that can be given to patients.
Not everyone can prescribe esketamine nasal spray. Similar to medications like clozapine and flibanserin, esketamine nasal spray is only available by prescription from clinicians registered under a Risk Evaluation and Mitigation Strategy (REMS) program. This is because serious adverse events can occur due to sedation and dissociation caused by esketamine and due to the potential for abuse.
Esketamine is intended to be given in conjunction with an oral antidepressant. Esketamine is for nasal use only. Each nasal spray device delivers two sprays containing a total of 28 mg esketamine.
Use two devices (for a 56 mg dose) or 3 devices (for an 84 mg dose), with a five-minute rest between use of each device.
Weeks 1 to 4: Administer twice per week
Day 1 starting dose: 56 mg
Subsequent doses: 56 mg or 84 mg
Weeks 5 to 8: Administer once weekly 56 mg or 84 mg
Week 9 and over: Administer every 2 weeks or once weekly 56 mg or 84 mg
Since some patients may experience nausea and vomiting, advise patients to avoid food for at least 2 hours before administration and to avoid drinking liquids at least 30 minutes prior to administration
Dosage forms and strengths (USA)
Nasal Spray: 28 mg of esketamine per device. Each nasal spray device delivers two sprays containing a total of 28 mg of esketamine.
Important! Please refer to the full Prescribing Information (see link below) before prescribing this medication.
Duman RS, Aghajanian GK, Sanacora G, Krystal JH. Synaptic plasticity and depression: new insights from stress and rapid-acting antidepressants. Nat Med. 2016 Mar;22(3):238-49. doi: 10.1038/nm.4050. PubMed PMID: 26937618; PubMed Central PMCID: PMC5405628.
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