From the Journals

More evidence backs adjunctive intranasal esketamine for refractory depression

 

Key clinical point: Adjunctive intranasal esketamine appears to lift treatment-resistant depression symptoms quickly, and the results last for more than 2 months “with a lower dosing frequency.”

Major finding: The MADRS mean score change for participants on the 28-mg dose was –4.2 (P = .2), –6.3 (P = .001) for those on the 56-mg dose, and –.9.0 (P greater than .001) for those on the 84-mg dose.

Study details: A phase 2 placebo-controlled study of 67 participants with treatment-resistant depression conducted in four phases at several outpatient treatment centers.

Disclosures: Janssen funded the study, and Dr. Daly and several of the other investigators are Janssen employees.

Source: Daly et al. JAMA Psychiatry. 2017 Dec. 27. doi: 10.1001/jamapsychiatry.2017.3739.

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Results promising, but caution is advised

The study by Daly et al. is of interest for two key reasons, wrote Daniel S. Quintana, PhD, and his associates in an accompanying editorial (JAMA Psychiatry. 2017 Dec 27. doi: 10.1001/jamapsychiatry.2017.3738). First, of interest is the drug’s impact on depressive symptoms as measured on the Montgomery-Åsberg Depression Rating Scale. Second, the delivery mechanism is of interest, particularly in light of the increased bioavailability made possible by intranasal delivery. However, esketamine should be used with caution for psychiatric patients, he said.

“One of the three most common adverse effects was perceptual changes or dissociative symptoms, which fits with the known effect of ketamine and should be further clarified before starting routine in clinical practice,” he wrote. “Moreover, several issues related to long-term use, including the potential for addiction and adverse effects (somatic and cognitive) need to be carefully assessed in forthcoming studies.”

Dr. Quintana is affiliated with Oslo University Hospital & Institute of Clinical Medicine at the University of Oslo.


 

FROM JAMA PSYCHIATRY

Esketamine – the S-enantiomer of the anesthetic ketamine – continues to look promising as an adjunctive treatment for refractory depression, phase 2 results of a four-phase multicenter trial suggested.

“We observed a significant and clinically meaningful treatment effect (vs. placebo) with 28-mg, 56-mg, and 84-mg doses of esketamine,” reported Ella J. Daly, MD, of Janssen, and her associates. The results were apparent 1 week after treatment, and they persisted over the follow-up phase, which lasted 8 weeks.

Results support further investigation of intranasal efficacy of esketamine for the management of [treatment-resistant depression] in larger trials,” Dr. Daly and her associates wrote in JAMA Psychiatry (2017 Dec 27. doi: 10.1001/jamapsychiatry.2017.3739).

In the study, patients aged 20-64 years with a diagnosis of major depressive disorder were recruited from several outpatient referral centers. All of the participants had treatment-resistant depression, defined by the study as an inadequate response despite the use of two or more antidepressants. Overall, 67 patients were randomized to receive one of the three doses of intranasal esketamine or a placebo nasal spray. In addition, participants continued to take oral antidepressants during the study period. People with a history of psychotic symptoms, use of substances such as alcohol and cannabis, or significant medical comorbidities were excluded.

Among participants in the treatment groups, the mean total score changes on the Montgomery-Åsberg Depression Rating Scale (MADRS) surpassed the MADRS score changes among those on placebo. Specifically, the mean MADRS score change for those on the 28-mg dose was –4.2 (P = 0.2), on the 56-mg dose was –6.3 (P = .001), and on the 84-mg dose was –9 (P less than .001).

The most common side effects among participants treated with esketamine were dizziness, headache, and dissociative symptoms. However, most adverse events were transient and “either mild or moderate in severity,” the investigators reported.

Dr. Daly and her associates cited several limitations, including the small sample size and the study’s exclusion criteria. Despite those limitations, Dr. Daly and her associates said, the results support further investigation of intranasal esketamine for treatment-resistant depression. They said a phase 3 study aimed at evaluating the frequency needed for dosing and duration of effect is underway.

Janssen funded the study. Dr. Daly and several of the other investigators are Janssen employees.

SOURCE: Daly et al. JAMA Psychiatry. 2017 Dec 27. doi: 10.1001/jamapsychiatry.2017.3739

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