Esketamine Clinic PRN Meds

[Hash Slinging Slasher]

---

Members don't see this ad.

Hey everyone,

I'm taking over an esketamine/Spravato clinic at our academic center and was looking to ask for some advice. For those who've worked or are currently working in esketamine/ketamine clinic, what PRN meds (if at all) do you use for hypertension or tachycardia?

At my institution we have the following scenarios and treatments delineated:

SCENARIOS
Scenario 1 (hypertension): BP > 180/110 on two separate measurements 5min apart OR BP > 200/120 on any single measurement
Scenario 2 (tachycardia): Sustained HR > 120min for 5min
Scenario 3 (borderline HR): HR < 70

CURRENT PRN TREATMENT
Scenario 1 AND/OR Scenario 2: Metoprolol tartrate 50 mg tab
Scenario 1 AND Scenario 3: Diltiazem 30 mg tab

Now this seemed a bit strange to me, as I was generally taught that you don't intervene for blood pressure or tachycardia from esketamine unless they're symptomatic (headache, changes to hearing vision, ataxia/vertigo, etc.

Any thoughts on what could be be better substitutes for PRN treatments in the above scenarios? I've come up with the below.

PROPOSED PRN TREATMENT
Scenario 1 ONLY: Clonidine 0.1 mg tab (if contraindicated then hydralazine 25 mg tab)
Scenario 2 ONLY: Metoprolol tartrate 50 mg tab (if contraindicated then diltiazem 30 mg tab)
Scenario 2 AND Scenario 1: Metoprolol tartrate 50 mg tab (if contraindicated then diltiazem 30 mg tab)
Scenario 1 AND Scenario 3: Hydralazine 25 mg tab (if contraindicated then prazosin 2 mg tab)

Any feedback or input would be greatly appreciated. I'm still very green to this and the literature search I've done hasn't produced much except for the below which recommended IV hydralazine/PO clonidine for hypertension and labetalol for tachycardia.

Key considerations for the use of ketamine and esketamine for the treatment of depression: focusing on administration, safety, and tolerability - PMC

Racemic ketamine, a derivative of phencyclidine, has been used as a dissociative anesthetic since 1970. In 2000, the first randomized controlled trial showed a rapid relief of depressive symptoms. Since then, intravenous ketamine and intranasal ...

pmc.ncbi.nlm.nih.gov

A randomized, double-blind, active placebo-controlled study of efficacy, safety, and durability of repeated vs single subanesthetic ketamine for treatment-resistant depression - PMC

The strategy of repeated ketamine in open-label and saline-control studies of treatment-resistant depression suggested greater antidepressant response beyond a single ketamine. However, consensus guideline stated the lack of evidence to support ...

pmc.ncbi.nlm.nih.gov

 

[claypigeon]

I'd stick with your initial thought and agree with cautioning against using anti hypertensives in asymptomatic cases. The BP almost always stabilize within 60-120 mins. Same for tachycardia. By the time the PO antihypertensive kicks in the BP has normalized or is close to doing so and then you drop the number too low. Better to pre treat them than treat after the fact. Same with tachycardia.

I don't use BP cutoffs in the PRN order but put "symptomatic elevated blood pressure" as part of the order set. That forces an assessment to be done rather than treating a #.

I don't see a consensus out there for what specific meds to use. I prefer clonidine. Our IM docs prefer norvasc. Quite a few curbside consults prefer hydralazine.

 

[comp1]

If you genuinely have a patient that is at risk of getting to 200/120, they should not be getting anywhere near Spravato. Heck, a lot of the clinical trials excluded people who regularly ran systolics greater than 140. I get that this is all theoretical, but I sincerely hope they are screening well enough to avoid you ever having to use this algorithm.

 

[SPsych6]

Clonidine is my preferred choice, but I have used propranolol for those that have an underlying panic disorder as well. I agree with only symptomatic treatment. I never used BP cut-offs for starting an antihypertensive. I do think it is important to really look at their pre-treatment BP and determine if it is a good option for the day. If they continually run high, I tend to recommend them be started on a medication by their PCP. Obviously, we can do it as well, but for legal issues, I just refer to the PCP to rule out underlying/reversible causes as a safety precaution. I personally have not run into anyone with bradycardia that I was concerned about. Definitely would not worry about a HR <70BPM

 

[Merovinge]

If you genuinely have a patient that is at risk of getting to 200/120, they should not be getting anywhere near Spravato. Heck, a lot of the clinical trials excluded people who regularly ran systolics greater than 140. I get that this is all theoretical, but I sincerely hope they are screening well enough to avoid you ever having to use this algorithm.

Yikes can you imagine having a stroke or MI while having just received Spravato? That sounds like a Hell on Earth experience to happen at a medical facility.

 

[TexasPhysician]

I mainly use Zofran. Probably used Clonidine 2x for panic-like reactions, not HTN.