​​In our clinic, we only use ESKETAMINE, as this S-form of ketamine is approved by the Food and Drug Administration for the treatment of drug-resistant depressive disorder.

ESKETAMINE – so-called RAAD = Rapid acting antidepressant:

It is a registered medicinal product with a clear indication and treatment procedure.

The FDA – the Food and Drug Administration in the USA approved it for the treatment of drug-resistant depression in March 2019. Its administration as a registered medicinal product is possible in the USA and Europe.

The main advantage of the treatment is rapid relief from symptoms of depression, especially in patients for whom conventional antidepressants do not work.

While conventional antidepressants begin to work in 4–6 weeks, the effect of esketamine often occurs within 1–2 weeks, in our experience usually around the fifth dose.

Mechanism of action

The mechanism of action of esketamine has not yet been fully elucidated.

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Esketamine acts through antagonism (blockade) of the NMDA receptor. This blockade, together with the activation of the AMPA receptor, leads to the release of large amounts of glutamate, which promotes the growth and connection of nerve cells in the cerebral cortex.

The rapid increase in the formation of new connections between nerve cells in the prefrontal cortex is considered to be the basis of the antidepressant effect. The prefrontal cortex suffers from a loss of volume in chronic depression or long-term stress.

The long-term antidepressant effect is induced only by adaptive neuroplastic changes. A change in the quality and number of nerve connections can be considered the main mechanism of antidepressant action.

Course of treatment

If the patient meets the indication criteria and the psychiatrist decides to administer Spravato (esketamine), treatment can be started almost immediately.

The initiation phase takes place during the first four weeks, when Spravato is applied twice a week.

After the initiation phase, the psychiatrist will evaluate the effect of the treatment so far and if there is at least partial improvement,

the patient moves on to the so-called maintenance phase. In this phase, the patient comes to Spravato only once a week. The first two months should not be interrupted for any reason (e.g. due to a planned operation or vacation).

The next phases are at a greater time interval, from once every 14 days to once a month, as agreed with our doctor.

The recommended treatment period is at least 6 months from the improvement of depressive symptoms.

​***The patient ALWAYS takes Spravato at the same time as SSRI antidepressants (sertraline, escitalopram, fluoxetine,..) or SNRI (venlafaxine). Using Spravato alone or in another regimen is a non-lege artis procedure.

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Education before the first application:

Before each Spravato application, the patient cannot eat for two hours, drink for half an hour and use nasal corticosteroids and decongestants for an hour before.

Before the application itself, the patient blows his nose and then does not blow his nose again.

The patient applies Spravato SELF in the form of a NASAL SPRAY under the supervision of a healthcare professional (doctor or nurse). One nasal spray applicator contains 28 mg, or two individual doses.

The patient gradually injects one into each nostril, closing the other nostril by pressing his finger. If the application is correct, a click will be heard and the hole in the upper part of the spray (indicator) will turn colored. There is a 5-minute break between applications. Then the application is repeated, if well tolerated, up to a maximum dose of 3 sprays, i.e. 84 mg.

The application cannot be done in the patient's home environment, it is tied to a healthcare facility.

The patient applies Spravato nasal spray while sitting with the head slightly tilted back (at an angle of approximately 45 degrees).

In our clinic, each patient has the opportunity to practice applying the spray using trial sprays.

After the application, the patient is observed in the medical facility for approximately 90-120 minutes. Blankets, pillows, books to borrow are available in the office at all times, and patients have the opportunity to listen to music.

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The most common side effects:

sedation, drowsiness

dissociation - a change in the perception of space, time, colors, as well as experiences of disconnection from the surroundings or from one's own body

increased blood pressure - blood pressure is regularly monitored by a nurse

nausea, vertigo (spinning of the head), less often vomiting

The side effects are not dramatic, usually disappear on the same day of administration. Spravato is very well tolerated by most patients.

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DIFFERENCES BETWEEN KETAMINE AND ESKETAMINE

KETAMINE

Ketamine is a combination of R and S-ketamine. According to the SPC (summary of product characteristics), ketamine does not have an indication for the treatment of any mental disorders. Currently, this is an off-label use, i.e. use outside of approved instructions.

The disadvantage of ketamine is its short-term effect, which ranges from 4 hours to a maximum of one week after administration.

Ketamine spreads (distributes) in the body within 10–15 minutes, while its complete breakdown (elimination) takes approximately 2–3 hours.

Studies with ketamine are criticized mainly for the small sample of patients who were included in the study.

Another factor is the great diversity in the doses administered - from a single administration to repeated applications of ketamine.