Name of the Procedure:

Esketamine Nasal Self-Administration (greater than 56 mg) Supervised by Healthcare Provider
HCPCS Code: G2083

Summary

Esketamine nasal spray is used to treat severe and treatment-resistant depression. Under this procedure, a patient self-administers a dose of esketamine greater than 56 mg while being supervised by a physician or other qualified health care professional to ensure proper use and monitor for immediate side effects.

Purpose

Conditions Addressed:

• Treatment-resistant depression (TRD)
• Major depressive disorder (MDD) with acute suicidal ideation or behavior

Goals/Outcomes:

• Rapid reduction in depressive symptoms
• Enhanced mood stability
• Prevention of depression-related hospitalization

Indications

Symptoms or Conditions Warranting the Procedure:

• Persistent depressive symptoms despite using two or more antidepressants
• Acute episodes of severe depression with suicidal thoughts or behaviors

Patient Criteria:

• Adults diagnosed with TRD or MDD
• Patients with no significant improvement from prior antidepressant treatment

Preparation

Pre-Procedure Instructions:

• Patients should avoid food for at least 2 hours and liquids for 30 minutes before administration.
• Disclose any current medications to the healthcare provider.

Diagnostic Tests:

• Baseline blood pressure and pulse readings
• Routine mental health evaluations

Procedure Description

1. Introduction: The healthcare provider explains the procedure and assesses patient readiness.
2. Preparation: The patient will be given a nasal spray device with the appropriate dose of esketamine (>56 mg).
3. Administration:
   • The patient will self-administer the spray while seated under the supervision of the healthcare provider.
   • The patient needs to follow the specific inhalation instructions to ensure effective dosing.
4. Monitoring:
   • The healthcare provider monitors the patient for at least 2 hours post-administration to watch for adverse effects like dissociation, increased blood pressure, and sedation.
5. Post-procedure: Patients are evaluated for safety before being allowed to leave.

Equipment Used:

• Esketamine nasal spray device
• Blood pressure cuff and monitoring tools

Anesthesia or Sedation:

• Not typically used; however, safety monitoring is essential.

Duration

The administration and subsequent monitoring typically take around 2 to 2.5 hours.

Setting

The procedure is performed in an outpatient clinic or a specialized treatment center with facilities to monitor patients for adverse reactions.

Personnel

• Physician or other qualified healthcare professional
• Nurses or medical assistants to assist in monitoring

Risks and Complications

Common Risks:

• Dizziness
• Nausea
• Dissociation or feeling disconnected from reality
• Increased blood pressure

Rare Complications:

• Severe allergic reactions
• Acute psychosis
• Long-term dependency risks

Management:

• Prompt medical intervention
• Adjustments in dosing plans for future sessions

Benefits

Expected Benefits:

• Rapid mood improvement often occurring within hours to days.
• Increased overall quality of life and daily functioning.

Recovery

Post-Procedure Care:

• Patients should have someone to drive them home.
• Avoid operating machinery or engaging in potentially hazardous activities until the following day.
• Follow-up appointments for additional doses or evaluations usually occur weekly or biweekly.

Recovery Time:

• Most patients feel back to baseline within 12-24 hours.

Alternatives

Alternative Treatments:

• Oral antidepressants
• Traditional psychotherapy
• Electroconvulsive therapy (ECT)
• Transcranial magnetic stimulation (TMS)

Pros and Cons:

• Oral Antidepressants: Safer but often less effective alone in TRD cases.
• ECT/TMS: Invasive or time-consuming but can be highly effective.
• Psychotherapy: Essential for long-term management but slower to show benefits.

Patient Experience

During Procedure:

• Mild discomfort from nasal administration
• Potential immediate sensations like dissociation or dizziness

After Procedure:

• Varying levels of drowsiness or lethargy
• Some residual dizziness or cognitive impairment

Pain Management:

• Typically, no pain involved; comfort measures include resting in a calm environment and ensuring hydration.