Esketamine

How it works

As the S-enantiomer of ketamine, it antagonises the NMDA glutamate receptor, leading to downstream changes in glutamatergic signalling thought to underlie its rapid antidepressant effects.

Prescribing in practice

• Because of the risks of sedation, dissociation and raised blood pressure, it must be administered under direct healthcare supervision with a period of post-dose observation.
• It carries potential for abuse and dependence and should be used within a controlled access framework.
• Patients must not drive or operate machinery on the day of administration until restful sleep the following day.

Monitoring

Monitor blood pressure, sedation and dissociative symptoms before and after each administration during the observation period.

Counselling the patient

• You will be observed for a period after each dose and should arrange transport home.
• Do not drive or use machinery until after a full night's sleep.
• Report any persistent dissociation, mood worsening or thoughts of self-harm.

Evidence & guidelines

Esketamine demonstrated efficacy in treatment-resistant depression in randomised trials and is appraised by NICE for use under supervised conditions.