AdultPediatricGeriatricDosage Forms & Strengths solution, intranasal: Schedule III 28mg/device; each nasal spray device delivers 2 sprays that total 28mg Available as a 56mg kit (two 28-mg nasal spray devices) or an 84mg kit (three 28-mg nasal spray devices) Treatment-resistant Depression Indicated in conjunction with an oral antidepressant for treatment-resistant depression (TRD) Adjust dose based on efficacy and tolerability At the end of the induction phase, evaluate evidence of therapeutic benefit to determine need for continued treatment Must be administered in healthcare facility under direct supervision Induction phase Weeks 1-4 Administer intranasally twice per week Day 1 starting dose: 56 mg Subsequent doses: 56 mg or 84 mg Maintenance phase Weeks 5-8 Administer intranasally once weekly 56 mg or 84 mg Week 9 and after Administer intranasally q2Week or once weekly; individualize dosing frequency to the least frequent dosing to maintain remission/response 56 mg or 84 mg Major Depressive Disorder Indicated for depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior Administer intranasally in conjunction with an oral antidepressant Must be administered in healthcare facility under direct supervision 84 mg twice per week x 4 weeks May reduce dose to 56 mg twice per week based on tolerability After 4 weeks of treatment, evaluate evidence of therapeutic benefit determine need for continued treatment Use in conjunction with an oral antidepressant beyond 4 weeks has not been systematically evaluated for treatment of depressive symptoms in patients with MDD with acute suicidal ideation or behavior Dosage Modifications Hepatic impairment Moderate (Child-Pugh class B): Higher AUC and half-life observed compared with normal hepatic function; may need to be monitored for longer period after dose administration Severe (Child-Pugh class C): Not studied, and therefore not recommended Renal impairment Renal dialysis: No clinical experience Dosing Considerations Must be administered under direct supervision of a healthcare provider during entire treatment session (ie, nasal administration and postadministration direct observation) Limitations of use Not approved as an anesthetic agent; safety and effectiveness not established Effectiveness in preventing suicide or in reducing suicidal ideation or behavior has not been demonstrated; use of esketamine intranasal does not preclude the need for hospitalization if clinically warranted, even if patients experience improvement after an initial dose Blood pressure monitoring Assess blood pressure before administration If baseline blood pressure is elevated (eg, >140 mm Hg systolic, >90 mm Hg diastolic), consider the risks of short-term increases in blood pressure and benefit of treatment Do not administer if increased blood pressure or intracranial pressure poses serious risk After dosing, reassess blood pressure at ~40 minutes (corresponds with peak plasma concentration) and subsequently as clinically warranted If blood pressure is decreasing and patient appears clinically stable for at least 2 hr, may discharge patient at the end of the postdose monitoring period; if not, continue to monitor Food and liquid ingestion Some patients may experience nausea and vomiting after administration Because of this, advise patients to avoid food for at least 2 hr before administration and to avoid drinking liquids at least 30 minutes before Nasal corticosteroids or decongestants Administer nasal corticosteroid or decongestant at least 1 hr before esketamine Safety and efficacy not establishedIn clinical trials, 14% of patients were aged 65 yr or older; no overall differences in safety profile were observed See adult dosingInteraction CheckerEnter a drug name and esketamine intranasalNo Results No Interactions Found Interactions FoundContraindicatedSerious - Use AlternativeSignificant - Monitor CloselyMinorAll Interactions Sort By: SeverityName Contraindicated (0)Serious - Use Alternative (3)buprenorphine, long-acting injectionbuprenorphine, long-acting injection and esketamine intranasal both increase sedation. Avoid or Use Alternate Drug. Limit use to patients for whom alternative treatment options are inadequatemetoclopramide intranasalesketamine intranasal, metoclopramide intranasal. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Avoid use of metoclopramide intranasal or interacting drug, depending on importance of drug to patient.olopatadine intranasalesketamine intranasal and olopatadine intranasal both increase sedation. Avoid or Use Alternate Drug. Coadministration increases risk of CNS depression, which can lead to additive impairment of psychomotor performance and cause daytime impairment. Monitor Closely (202)acetaminophen/pamabrom/pyrilamineesketamine intranasal, acetaminophen/pamabrom/pyrilamine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.acetazolamideesketamine intranasal, acetazolamide. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.acrivastineesketamine intranasal, acrivastine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.acrivastine and esketamine intranasal both increase sedation. Use Caution/Monitor.alfentanilesketamine intranasal, alfentanil. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.alprazolamesketamine intranasal, alprazolam. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.amisulprideamisulpride and esketamine intranasal both increase sedation. Use Caution/Monitor.amitriptylineesketamine intranasal, amitriptyline. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.amobarbitalesketamine intranasal, amobarbital. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.amoxapineesketamine intranasal, amoxapine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.amphetamineesketamine intranasal, amphetamine. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .amphetamine polistirexesketamine intranasal, amphetamine polistirex. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .arbaclofenesketamine intranasal, arbaclofen. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.aripiprazoleesketamine intranasal, aripiprazole. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.armodafinilesketamine intranasal, armodafinil. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .asenapineesketamine intranasal, asenapine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.asenapine transdermalasenapine transdermal and esketamine intranasal both increase sedation. Use Caution/Monitor.atomoxetineesketamine intranasal, atomoxetine. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .avapritinibavapritinib and esketamine intranasal both increase sedation. Use Caution/Monitor.baclofenesketamine intranasal, baclofen. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.belladonna and opiumesketamine intranasal, belladonna and opium. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.benperidolesketamine intranasal, benperidol. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.benzhydrocodone/acetaminophenesketamine intranasal, benzhydrocodone/acetaminophen. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.brexanolonebrexanolone, esketamine intranasal. Either increases toxicity of the other by sedation. Use Caution/Monitor.brexpiprazoleesketamine intranasal, brexpiprazole. Either increases levels of the other by sedation. Modify Therapy/Monitor Closely.brimonidineesketamine intranasal, brimonidine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.brivaracetamesketamine intranasal, brivaracetam. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.brompheniramineesketamine intranasal, brompheniramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.buprenorphineesketamine intranasal, buprenorphine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.buprenorphine transdermalesketamine intranasal, buprenorphine transdermal. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.buspironeesketamine intranasal, buspirone. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.butabarbitalesketamine intranasal, butabarbital. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.butalbitalesketamine intranasal, butalbital. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.butorphanolesketamine intranasal, butorphanol. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.caffeineesketamine intranasal, caffeine. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .calcium/magnesium/potassium/sodium oxybatesesketamine intranasal, calcium/magnesium/potassium/sodium oxybates. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.cannabidiolesketamine intranasal, cannabidiol. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.carbamazepineesketamine intranasal, carbamazepine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.carbinoxamineesketamine intranasal, carbinoxamine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.cariprazineesketamine intranasal, cariprazine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.carisoprodolesketamine intranasal, carisoprodol. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.cenobamatecenobamate, esketamine intranasal. Either increases effects of the other by sedation. Use Caution/Monitor.cetirizineesketamine intranasal, cetirizine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.chlordiazepoxideesketamine intranasal, chlordiazepoxide. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.chlorpheniramineesketamine intranasal, chlorpheniramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.chlorpromazineesketamine intranasal, chlorpromazine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.chlorzoxazoneesketamine intranasal, chlorzoxazone. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.clemastineesketamine intranasal, clemastine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.clomipramineesketamine intranasal, clomipramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.clonazepamesketamine intranasal, clonazepam. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.clonidineesketamine intranasal, clonidine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.esketamine intranasal, clonidine. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .clorazepateesketamine intranasal, clorazepate. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.clozapineesketamine intranasal, clozapine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.codeineesketamine intranasal, codeine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.cyclobenzaprineesketamine intranasal, cyclobenzaprine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.cyproheptadineesketamine intranasal, cyproheptadine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.dantroleneesketamine intranasal, dantrolene. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.daridorexantesketamine intranasal and daridorexant both increase sedation. Modify Therapy/Monitor Closely. Coadministration increases risk of CNS depression, which can lead to additive impairment of psychomotor performance and cause daytime impairment. desfluraneesketamine intranasal, desflurane. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.desipramineesketamine intranasal, desipramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.desloratadineesketamine intranasal, desloratadine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.deutetrabenazineesketamine intranasal, deutetrabenazine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.dexbrompheniramineesketamine intranasal, dexbrompheniramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.dexchlorpheniramineesketamine intranasal, dexchlorpheniramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.dexmethylphenidateesketamine intranasal, dexmethylphenidate. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .dextroamphetamineesketamine intranasal, dextroamphetamine. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .diazepamesketamine intranasal, diazepam. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.diazepam intranasaldiazepam intranasal, esketamine intranasal. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Coadministration may potentiate the CNS-depressant effects of each drug.diethylpropionesketamine intranasal, diethylpropion. Either increases toxicity of the other by sympathetic (adrenergic) effects, including increased blood pressure and heart rate. Use Caution/Monitor. Closely monitor blood pressure with concomitant use of esketamine nasal with stimulants. .difelikefalindifelikefalin and esketamine intranasal both increase sedation. Use Caution/Monitor.dimenhydrinateesketamine intranasal, dimenhydrinate. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.diphenhydramineesketamine intranasal, diphenhydramine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.diphenoxylate hclesketamine intranasal, diphenoxylate hcl. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.dosulepinesketamine intranasal, dosulepin. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.doxepinesketamine intranasal, doxepin. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.doxylamineesketamine intranasal, doxylamine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.droperidolesketamine intranasal, droperidol. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.efavirenzesketamine intranasal, efavirenz. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.emedastineesketamine intranasal, emedastine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.estazolamesketamine intranasal, estazolam. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.eszopicloneesketamine intranasal, eszopiclone. Either increases toxicity of the other by sedation. Use Caution/Monitor.ethanolesketamine intranasal, ethanol. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.ethosuximideesketamine intranasal, ethosuximide. Either increases toxicity of the other by sedation. Use Caution/Monitor.ethotoinesketamine intranasal, ethotoin. Either increases toxicity of the other by sedation. Use Caution/Monitor.ezogabineesketamine intranasal, ezogabine. Either increases levels of the other by sedation. Use Caution/Monitor.felbamateesketamine intranasal, felbamate. Either increases toxicity of the other by sedation. Use Caution/Monitor.fenfluraminefenfluramine, esketamine intranasal. Either increases effects of the other by serotonin levels. Use Caution/Monitor. Coadministration with drugs that increase serotoninergic effects may increase the risk of serotonin syndrome.fentanylesketamine intranasal, fentanyl. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.fentanyl intranasalesketamine intranasal, fentanyl intranasal. Either increases toxicity