Neuropsychiatric and motor impairments: Spravato has been reported to cause somnolence, sedation, dissociative symptoms, perception disturbances, dizziness, vertigo and anxiety during the clinical trials (see Adverse Reactions). These effects may impair attention, judgment, thinking, reaction speed and motor skills. At each treatment session, patients should be monitored under the supervision of a healthcare professional to assess when the patient is considered stable based on clinical judgement (see Effects on ability to drive and use machines as follows).
Respiratory depression: Respiratory depression may occur at high doses following rapid intravenous injection of esketamine or ketamine when used for anaesthesia. No case of respiratory depression was observed in clinical trials with esketamine nasal spray (Spravato); rare cases of deep sedation have been reported. Concomitant use of Spravato with CNS depressants may increase the risk for sedation (see Interactions). Close monitoring is required for sedation and respiratory depression.
Effect on blood pressure: Spravato can cause transient increases in systolic and/or diastolic blood pressure which peak at approximately 40 minutes after administration of the medicinal product and last approximately 1-2 hours (see Adverse Reactions). A substantial increase in blood pressure could occur after any treatment session. Spravato is contraindicated in patients for whom an increase in blood pressure or intracranial pressure poses a serious risk (see Contraindications). Before prescribing Spravato, patients with other cardiovascular and cerebrovascular conditions should be carefully assessed to determine whether the potential benefits of Spravato outweigh its risks.
In patients whose blood pressure prior to dose administration is judged to be elevated (as a general guide: >140/90 mmHg for patients <65 years of age and >150/90 mmHg for patients ≥65 years of age), it is appropriate to adjust lifestyle and/or pharmacologic therapies to reduce blood pressure before starting treatment with Spravato. If blood pressure is elevated prior to Spravato administration a decision to delay Spravato therapy should take into account the balance of benefit and risk in individual patients.
Blood pressure should be monitored after dose administration. Blood pressure should be measured around 40 minutes post-dose and subsequently as clinically warranted until values decline. If blood pressure remains elevated for a prolonged period of time, assistance should promptly be sought from practitioners experienced in blood pressure management. Patients who experience symptoms of a hypertensive crisis should be referred immediately for emergency care.
Patients with clinically significant or unstable cardiovascular or respiratory conditions: Only initiate treatment with Spravato in patients with clinically significant or unstable cardiovascular or respiratory conditions if the benefit outweighs the risk. In these patients, Spravato should be administered in a setting where appropriate resuscitation equipment and healthcare professionals with training in cardiopulmonary resuscitation are available. Examples of conditions which should be considered include, but are not limited to: Significant pulmonary insufficiency, including COPD; Sleep apnoea with morbid obesity (BMI ≥35); Patients with uncontrolled brady- or tachyarrhythmias that lead to haemodynamic instability; Patients with a history of an MI. These patients should be clinically stable and cardiac symptom free prior to administration; Haemodynamically significant valvular heart disease or heart failure (NYHA Class III-IV).
Suicide/suicidal thoughts or clinical worsening: Depression is associated with an increased risk of suicidal thoughts, self-harm and suicide (suicide-related events). This risk persists until significant remission occurs, therefore, patients should be closely monitored. It is general clinical experience that the risk of suicide may increase in the early stages of recovery.
Patients with a history of suicide-related events or those exhibiting a significant degree of suicidal ideation prior to commencement of treatment are known to be at greater risk of suicidal thoughts or suicide attempts and should receive careful monitoring during treatment.
Close supervision of patients and in particular those at high risk should accompany treatment especially in early treatment and following dose changes. Patients (and caregivers of patients) should be alerted to the need to monitor for any clinical worsening, suicidal behaviour or thoughts and unusual changes in behaviour and to seek medical advice immediately if these symptoms present.
Drug abuse, dependence, withdrawal: Individuals with a history of drug abuse or dependence may be at greater risk for abuse and misuse of Spravato. Prior to prescribing Spravato, each patient's risk for abuse or misuse should be assessed and patients receiving esketamine should be monitored for the development of behaviours or conditions of abuse or misuse, including drug seeking behaviour, while on therapy.
Dependence and tolerance have been reported with prolonged use of ketamine. In individuals who were dependent on ketamine, withdrawal symptoms of cravings, anxiety, shaking, sweating and palpitations have been reported upon discontinuing ketamine.
Ketamine, the racemic mixture of arketamine and esketamine, is a medicinal product that has been reported to be abused. The potential for abuse, misuse and diversion of Spravato is minimised due to the administration taking place under the direct supervision of a healthcare professional. Spravato contains esketamine and may be subject to abuse and diversion.
Other populations at risk: Spravato should be used with caution in patients with the following conditions. These patients should be carefully assessed before prescribing Spravato and treatment initiated only if the benefit outweighs the risk: Presence or history of psychosis; Presence or history of mania or bipolar disorder; Hyperthyroidism that has not been sufficiently treated; History of brain injury, hypertensive encephalopathy, intrathecal therapy with ventricular shunts, or any other condition associated with increased intracranial pressure.
Severe hepatic impairment: Due to expected increase in exposure and lack of clinical experience, Spravato is not recommended in patients with Child-Pugh class C (severe) hepatic impairment.
Hepatotoxicity has been reported with chronic ketamine use, therefore, the potential for such an effect due to long-term use of Spravato cannot be excluded.
Urinary tract symptoms: Urinary tract and bladder symptoms have been reported with Spravato use (see Adverse Reactions). It is recommended to monitor for urinary tract and bladder symptoms during the course of treatment and refer to an appropriate healthcare provider when symptoms persist.
Effects on ability to drive and use machines: Spravato has a major influence on the ability to drive and use machines. In clinical studies, Spravato has been reported to cause somnolence, sedation, dissociative symptoms, perception disturbances, dizziness, vertigo and anxiety (see Adverse Reactions). Before Spravato administration, patients should be instructed not to engage in potentially hazardous activities requiring complete mental alertness and motor coordination, such as driving a vehicle or operating machinery, until the next day following a restful sleep (see Precautions).
Use in the Elderly: Elderly patients (65 years of age and older) treated with Spravato may have a greater risk of falling once mobilised, therefore, these patients should be carefully monitored.