The U.S. Food and Drug Administration (FDA) has granted approval for Spravato (esketamine) CIII nasal spray as a standalone treatment for adults grappling with major depressive disorder (MDD) who have shown an inadequate response to at least two oral antidepressants. This decision marks a significant advancement in the treatment landscape for treatment-resistant depression (TRD), offering a new option for patients who have not found relief through traditional therapies.
This approval, announced by Johnson & Johnson on January 21, 2025, is based on data from a randomized, double-blind, multicenter, placebo-controlled study. The study demonstrated that Spravato, when used as a monotherapy, led to a rapid and superior improvement in the Montgomery-Asberg Depression Rating Scale (MADRS) total score compared to placebo. A post-hoc analysis further revealed numerical improvements across all 10 MADRS items at day 28. At week 4, 22.5% of patients taking Spravato achieved remission (MADRS total score ≤ 12), compared to only 7.6% of patients taking a placebo.
Clinical Efficacy and Safety Profile
The clinical trial results highlight the potential of Spravato to provide rapid relief for individuals with TRD. According to Dr. Bill Martin, Global Therapeutic Area Head, Neuroscience, Johnson & Johnson Innovative Medicine, patients may experience improvements in depressive symptoms as early as 24 hours and at 28 days – without the need for daily oral antidepressants.
The safety profile of Spravato as a standalone treatment was found to be consistent with the existing body of clinical and real-world data when used in conjunction with an oral antidepressant, and no new safety concerns were identified. However, due to the risks of serious adverse outcomes resulting from sedation, dissociation, respiratory depression, abuse, and misuse, Spravato is only available through a restricted program called the Spravato Risk Evaluation and Mitigation Strategy (REMS) Program.
Mechanism of Action and Administration
Spravato is unique in its mechanism of action, targeting glutamate, the most abundant excitatory neurotransmitter in the brain. While the exact mechanism by which esketamine exerts its antidepressant effect is unknown, it is believed to work differently by acting on a pathway in the brain that affects glutamate. The drug is administered as a nasal spray under the supervision of a healthcare provider in a certified healthcare setting.
Impact on Treatment-Resistant Depression
Major depressive disorder affects an estimated 21 million adults in the U.S., with approximately one-third of these individuals not responding adequately to oral antidepressants alone. This subset of patients is considered to have treatment-resistant depression, which has a significant negative impact on their lives and contributes to a high economic burden. After trying their third oral antidepressant, approximately 86% of patients do not achieve remission.
Expert Perspectives
Dr. Gregory Mattingly, President, Midwest Research Group and Founding Partner, St. Charles Psychiatric Associates, emphasized the real-world impact Spravato can have on patients' lives. He stated that now that it is also available as a monotherapy, healthcare providers have the freedom to further personalize treatment plans based on individual needs, so patients can experience the efficacy of Spravato in as little as 24 hours, through day 28, without the need for a daily oral antidepressant.
Considerations and Precautions
It is important to note that Spravato is not for use as a medicine to prevent or relieve pain (anesthetic). It is also not known if Spravato is safe and effective for use in preventing suicide or in reducing suicidal thoughts or actions. The medication carries a boxed warning for the risks of sedation, dissociation, respiratory depression, abuse and misuse, and suicidal thoughts and behaviors.
Common adverse events associated with Spravato include dissociation, dizziness, nausea, sedation, vertigo, hypoesthesia, anxiety, lethargy, increased blood pressure, vomiting, feelings of drunkenness, and headache. Patients should avoid driving, operating machinery, or doing anything where they need to be completely alert after taking Spravato until the next day following a restful sleep.
