Safety and Tolerability
Established safety profile1
|ADVERSE REACTIONS IN >2% OF PATIENTS TREATED WITH SPRAVATO™ AND PLACEBO IN THE SHORT-TERM STUDIES*|
|Adverse reaction||n (% of population)||Adverse Reaction||n (% of population)|
|Dissociation||142 (41%)||21 (9%)||Nasal discomfort||23 (7%)||11 (5%)|
|Dizziness||101 (29%)||17 (8%)||Throat irritation||23 (7%)||9 (4%)|
|Nausea||98 (28%)||19 (9%)||Feeling drunk||19 (5%)||1 (0.5%)|
|Sedation||79 (23%)||21 (9%)||Dry mouth||19 (5%)||7 (3%)|
|Vertigo||78 (23%)||6 (3%)||Hyperhidrosis||14 (4%)||5 (2%)|
|Headache||70 (20%)||38 (17%)||Euphoric mood||15 (4%)||2 (1%)|
|Dysgeusia||66 (19%)||30 (14%)||Dysarthria||15 (4%)||0 (0%)|
|Hypoesthesia||63 (18%)||5 (2%)||Tremor||12 (3%)||2 (1%)|
|Anxiety||45 (13%)||14 (6%)||Oropharyngeal pain||9 (3%)||5 (2%)|
|Lethargy||37 (11%)||12 (5%)||Mental impairment||11 (3%)||2 (1%)|
|Blood pressure increased||36 (10%)||6 (3%)||Constipation||11 (3%)||3 (1%)|
|Vomiting||32 (9%)||4 (2%)||Pollakiuria||11 (3%)||1 (0.5%)|
|Insomnia||29 (8%)||16 (7%)||Feeling abnormal||12 (3%)||0 (0%)|
|Diarrhea||23 (7%)||13 (6%)||Tachycardia||6 (2%)||1 (0.5%)|
Discontinuation rates due to adverse events were <5% across short- and long-term clinical studies1
*At any dose and greater rate than patients receiving placebo nasal spray.
Sedation was reported in 2 ways in the clinical studies: through adverse event reports, and by using the Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/s).
• Adverse events of sedation were reported in approximately 23% of patients treated with SPRAVATO™ at any dose (N=346)
• Based on the MOAA/s, 49% to 61% of patients treated with SPRAVATO™ developed sedation
• 0.3% of patients treated with SPRAVATO™ experienced loss of consciousness†
• Because of the possibility of delayed or prolonged sedation, patients must be monitored by a healthcare professional for at least 2 hours following each treatment session, followed by an assessment to determine when the patient is considered clinically stable and ready to leave
†Based on the MOAA/s scale.
Dissociation was reported in 2 ways in the clinical studies: through adverse event reports, and by using the Clinician-Administered Dissociative States Scale (CADSS).
• Adverse events of dissociation were reported in approximately 41% of patients treated with SPRAVATO™ at any dose (N=346)
• Based on the CADSS, 61% to 75% of patients treated with SPRAVATO™ developed dissociative or perceptual changes
• In clinical trials, dissociation was reported as transient and occurred on the day of dosing
• Because of the risks of dissociation, patients must be monitored by a healthcare professional for at least 2 hours at each treatment session, followed by an assessment to determine when the patient is considered clinically stable and ready to leave the healthcare setting
• Given its potential dissociative effects, carefully assess patients with psychosis before administering SPRAVATO™; treatment should be initiated only if the benefit outweighs the risk
WHAT IS DISSOCIATION?‡
The most common psychological effects of SPRAVATO™ have been dissociative/perceptual changes (including distortion of time and space, and illusions), derealization, and depersonalization. Patients may describe these symptoms as feeling disconnected from themselves, their thoughts and feelings, space and time.
‡Based on the CADSS.
• SPRAVATO™ is a Schedule III controlled substance and may be subject to abuse and diversion. Assess each patient's risk for abuse or misuse prior to prescribing SPRAVATO™, and monitor all patients receiving SPRAVATO™ for the development of these behaviors or conditions, including drug-seeking behavior, while on therapy
• Individuals with a history of drug abuse or dependence are at greater risk; therefore, use careful consideration prior to treatment of individuals with a history of substance use disorder. Monitoring for signs of abuse is recommended
• Physical dependence has been reported with prolonged off-label use of ketamine. There were no withdrawal symptoms captured up to 4 weeks after cessation of SPRAVATO™ treatment. Monitor SPRAVATO™-treated patients for symptoms and signs of physical dependence upon discontinuation of the drug
• Before SPRAVATO™ administration, instruct patients not to engage in potentially hazardous activities, such as driving a motor vehicle or operating machinery, until the next day after a restful sleep
• Patients will require transportation from the treatment center after administration
• SPRAVATO™ is contraindicated in patients with:
– Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial, and peripheral arterial vessels) or arteriovenous malformation
– History of intracerebral hemorrhage
– Hypersensitivity to esketamine, ketamine, or to any of the excipients
• CNS depressants: closely monitor for sedation with concomitant use of SPRAVATO™ with CNS depressants, including benzodiazepines, opioids, and alcohol
• Psychostimulants and monoamine oxidase inhibitors (MAOIs): closely monitor for blood pressure with concomitant use of SPRAVATO™ with psychostimulants (including amphetamines, methylphenidate, modafinil, and armodafinil) and MAOIs
• SPRAVATO™ caused increases in systolic blood pressure (SBP) and/or diastolic blood pressure (DBP), which peak at approximately 40 minutes after administration and last approximately 4 hours:
– 40 minutes post dose, mean placebo-adjusted increases in SBP=7 to 9 mmHg and DBP=4 to 6 mmHg
– If blood pressure is decreasing and the patient appears clinically stable for at least 2 hours, the patient may be discharged at the end of the post-dose monitoring period
• Assess blood pressure prior to, and approximately 40 minutes after dosing with SPRAVATO™ and subsequently as clinically warranted until values decline
– Do not administer SPRAVATO™ if an increase in blood pressure or intracranial pressure poses a serious risk
– 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
• SPRAVATO™ is not recommended for women who are pregnant or may become pregnant, or in women who are breastfeeding. Women who become pregnant should stop taking SPRAVATO™ and the patient should be counseled about the potential risk to the fetus
• SPRAVATO™ was not assessed in pregnant women. SPRAVATO™ may cause fetal harm when administered to pregnant women
• In a study in healthy volunteers, a single dose of SPRAVATO™ caused cognitive performance decline 40 minutes post dose. Cognitive performance and mental effort were comparable between SPRAVATO™ and placebo at 2 hours post dose
• Long-term cognitive and memory impairment have been reported with repeated off-label ketamine misuse or abuse
• No adverse effects of SPRAVATO™ nasal spray on cognitive functioning were observed in a one-year open-label safety study; however, the long-term cognitive effects of SPRAVATO™ have not been evaluated beyond one year
SPRAVATO™ REMS goals
Discontinuation rates due to adverse events were <5% across short- and long-term clinical trials1§
§Based on data from Study 2 maintenance phase.
Adverse events leading to SPRAVATO™ discontinuation in more than 2 patients included anxiety (1.2%), depression (0.9%), blood pressure increased (0.6%), dizziness (0.6%), suicidal ideation (0.5%), dissociation (0.4%), nausea (0.4%), vomiting (0.4%), headache (0.3%), muscular weakness (0.3%), vertigo (0.2%), hypertension (0.2%), panic attack (0.2%), and sedation (0.2%).1
For additional information, please see full Prescribing Information, including Boxed WARNINGS.
1.SPRAVATO™ [Prescribing Information]. Titusville, NJ: Janssen Pharmaceuticals, Inc. March 2019.