Esketamine and Caffeine

Esketamine can cause significant increases in blood pressure, and using it with caffeine may increase the risk. Let your doctor know if you have been using caffeine prior to getting treatment with esketamine. You may need a dose adjustment or more frequent monitoring of your blood pressure to safely use both medications. It is important to tell your doctor about all other medications you use, including vitamins and herbs. Do not stop using any medications without first talking to your doctor.

MONITOR CLOSELY: Coadministration with psychostimulants (e.g., amphetamines) or monoamine oxidase inhibitors (MAOIs) may potentiate the hypertensive effects of esketamine. According to the prescribing information, esketamine causes increases in systolic and/or diastolic blood pressure (BP) at all recommended doses. Increases in BP peak approximately 40 minutes after esketamine administration and last about 4 hours. In clinical studies, approximately 8% to 17% of esketamine-treated patients experienced an increase of more than 40 mmHg in systolic BP and/or 25 mmHg in diastolic BP within 1.5 hours after administration at least once during the first 4 weeks of treatment, compared to 1% to 3% of placebo-treated patients. A substantial increase in BP could occur after any dose, even if smaller BP effects were observed with previous administrations. The mean placebo-adjusted increases in systolic and diastolic blood pressure (SBP and DBP) over time were about 7 to 9 mmHg in SBP and 4 to 6 mmHg in DBP at 40 minutes post-dose and 2 to 5 mmHg in SBP and 1 to 3 mmHg in DBP at 1.5 hours post-dose in patients receiving esketamine with oral antidepressants.

MANAGEMENT: Caution is advised and blood pressure should be closely monitored during concomitant use of esketamine with psychostimulants or MAOIs. All patients receiving esketamine should have BP assessed prior to administration. If BP is elevated (e.g., >140 mmHg systolic, >90 mmHg diastolic), a delay in esketamine treatment may be necessary, taking into consideration the benefits versus risks in individual patients. BP should be monitored for at least 2 hours after esketamine administration, starting at approximately 40 minutes post-dose and subsequently as clinically warranted. In patients with a history of hypertensive encephalopathy, more intensive monitoring is warranted due to increased risk for developing encephalopathy with even small increases in BP. If at any point BP is elevated and remains high, promptly seek assistance from practitioners experienced in BP management. Patients experiencing symptoms of a hypertensive crisis (e.g., chest pain, shortness of breath) or hypertensive encephalopathy (e.g., sudden severe headache, visual disturbances, seizures, diminished consciousness or focal neurological deficits) should be immediately referred for emergency care.