Evolving Management Strategies for Treatment-Resistant Depression - Episode 9
Best practices that can be applied when working with patients and training staff on proper ways to administer intranasal esketamine therapy for treatment-resistant depression in a supervised medical setting.
Steven Levine, MD: As part of the REMS [Risk Evaluation and Mitigation Strategy], one of the requirements is that the medicine is administered in a REMS-certified center with supervised administration. Angelos, could you talk about the ease of self-administering nasal sprays for patients?
Angelos Halaris, MD, PhD, APA, ACNP, CINP: Yes. It’s very easy. The patient has to be instructed, which you do the first time. They’re always under observation. We make sure their head is tilted at a 45-degree angle. They rest in a chair that can recline. We elevate their legs. We want to make sure they are really comfortable for 2 hours, or possibly longer if necessary. Then we show them how to do it. We practice first without the spray vial. There are practice vials available. We teach them how to do that before we get to the real medication. We tell them how to administer through the nostrils, changing the nostrils, how to make sure they don’t come in with a cold, runny nose, a cough, or anything that could interfere with the absorption of esketamine. That is all done from the get-go.
We ask them these questions upon arrival. If everything is clear, we remind them how to do it. They administer it themselves, but we watch them do it. We describe how they should sniff it a little and take 2 or 3 not-too-deep breaths through the nose, because if they breathe too heavily or too strongly, it goes right back down the throat. In fact, today, a patient told me, “Sometimes I take it in very vigorously and then I feel it in my throat.” That’s not good, because we lose some of it. That’s done under guidance and observation, but the administration is very easy. It’s like using a nasal spray for a common cold.
Lisa Harding, MD: My 2 cents on that is similar to what Patricia was saying. The patients feel an autonomy. How often do they get to come to the doctor’s office and control how they get the medication? The company provides trainer devices. I have a different process. I have a process of consent, which is a different appointment than when they first come. In that consent process, the patient is allowed to go into the treatment room and sit in a chair that is similar to the one that they will sit in when they get their treatment. They play with the trainer device. Sometimes, it’s a very strange thing for the newer pharmacies to understand.
This is one of the drugs that’s self-administered, but under the supervision of a doctor. They’re allowed to reset the device and play with it as many times as they like. I also have a check-in and check-out process. It gives my patients confidence. We make sure they haven’t had anything to eat 4 hours before administration and nothing to drink 30 minutes before. We have them blow their nose before each device. Most of my patients resoundingly have asked me to tell the drug company to flavor it. It’s the same thing Angelos was saying. Patients will say, “This tastes like metal. Can’t they make it bubblegum?”
We talk through all of these things. I have a stock of lollipops in the room. They are for my patients who really can’t take it. They get a lollipop after the first insufflation. I’ve also found it really helpful to tell patients that it’s not like one of the conventional over-the-counter nasal sprays, because it does snap. Most patients have a tendency to pull back with something close to their face that snaps, so I’ve found it helpful to tell them there’s a back of the headrest that pulls up because the device snaps and they tend to pull back sometimes. It’s little nuances like that. My advice for providers is to take one of the trainers, go through the training video that’s on the website, do it yourself, and observe the things that you’re feeling in your body when you’re doing it. Give that same advice.
Patricia Ares-Romero, MD, FASAM: I love that, Lisa. I love that tip on the lollipop. For me, it’s a little hybrid. When a patient comes in for a consultation, if it’s not one of my patients, that’s usually when we let them do that. We show them the treatment rooms, we let them sit down and feel comfortable, we give them the treatments, we talk about the treatment, we get consent from them, and that’s when we send the paperwork for REMS.
The other thing I do from the beginning is try to make patients understand that it’s like a procedure. It’s like going to get a colonoscopy. You get all these instructions before you come in. You can’t drink, you can’t eat, you have to make sure that you do all these things, and you have somebody bring you. We did it that way, and the patients have been great. Make sure you take your hypertensive medication. I remember the first time I had a patient and we told him not to drink or eat. He showed up, but he hadn’t taken his hypertensive medication. Guess what? He couldn’t receive treatment that day because his blood pressure was all over the place. We make sure we do that. We make sure we tell the patient that if they take a benzodiazepine, they can’t take them that day. We want to make sure they do not take anything that’s sedative. Those are the types of things we do prior to their appointment. When they come in, our nurse makes sure we go through that checklist as well. But I adore the lollipop idea.
Lisa Harding, MD: Yes, bubblegum flavor is a hit. It masks the flavor of anything.
Transcript Edited for Clarity