TMS ACT

SPRAVATO (Esketamine)
Doctor Initiation Guide

For treating doctors — ketamine treatment initiation reference

All patients — before first session

1
Confirm treatment-resistant depression criteriaPatient must have trialled 2 or more antidepressants from different classes without adequate response before SPRAVATO is indicated.
2
Ensure there are no contraindications
  • Aneurysmal vascular disease (including thoracic and abdominal aorta, intracranial and peripheral arterial vessels) or arteriovenous malformation
  • Known history of intracerebral haemorrhage
  • Conditions where an increase in blood pressure or intracranial pressure poses a serious risk
  • Known hypersensitivity to esketamine, ketamine, or any excipients
  • Severe hepatic impairment (Child-Pugh class C)
  • Pregnancy — may cause fetal harm; discontinue if patient becomes pregnant during treatment
  • Breastfeeding — esketamine is present in human milk; risks not yet established
3
Check blood pressureMust be assessed before the patient arrives for their first session. SPRAVATO can raise BP — identify elevated baseline early. Contraindicated where BP increase poses serious risk.
4
Prescribe a new antidepressantA new oral antidepressant must be prescribed and commenced in conjunction with SPRAVATO, as per TGA guidelines.
5
Provide patient guideGive the patient the SPRAVATO patient guide to read before their first session.
6
Signed consent formPatient must sign the SPRAVATO Information and Consent Form before first dose. Ensure they have read and understood the patient guide.Download Consent Form

Funding type

DVA — Department of Veterans’ Affairs
1
Complete KSET baseline formRequired at commencement. Patient may pre-fill; clinician must review and countersign.Download KSET Baseline Form
2
Submit CHO applicationA Controlled Health Order (CHO) application must be submitted before a script can be issued.
Provide CHO approval to TMS ACT
3
Issue PBS scriptDVA patients access medication via the PBS.
Script must be provided to TMS ACT
4
No prior approval neededDVA covers up to 28 sessions per 6-month period with no pre-approval required.
✓ Commence treatment
5
KSET follow-up form — every 6 monthsUse the Follow-Up form (not the baseline form). Covers symptoms experienced outside of treatment sessions.Download KSET Follow-Up Form
PBS — Pharmaceutical Benefits Scheme
1
Submit CHO applicationA Controlled Health Order (CHO) application must be submitted before a script can be issued.
Provide CHO approval to TMS ACT
2
Issue PBS scriptStandard PBS access applies. No special authorisation required for the medication.
Script must be provided to TMS ACT
3
No prior approval requiredTreatment may commence once all pre-treatment checks are completed.
✓ Commence treatment
Medication cost (per month)
Standard$25.00
Healthcare card holders$7.70
Session cost: $300 per session.
Insurance — Private insurer
1
Do not commence until a quote is approvedAnna will organise the quote — treatment cannot be scheduled until written approval is received from the insurer.
⚠ Awaiting quote & approval
2
Send Anna the following before she can proceed
Required from the treating doctor:
  • Patient’s full name
  • Insurance company and policy details
  • Claim number
  • A letter to the insurer outlining the clinical reasons for undertaking SPRAVATO treatment
3
Submit CHO applicationA Controlled Health Order (CHO) application must be submitted before a script can be issued.
Provide CHO approval to TMS ACT
4
Issue a private script — not PBSInsurance patients cannot access SPRAVATO under the PBS. A private script must be written.
Script must be provided to TMS ACT

Starting dose

65 and over
28mg
Starting dose
Under 65
56mg
Starting dose
All patients
84mg
Target if tolerated
i
Titrate to 84mg based on tolerabilityDose is adjusted upward from the starting dose based on patient response and tolerability. All patients — regardless of starting dose — may titrate to 84mg.

Dosing schedule — all patients

Induction
2× per week
For 4 weeks (8 sessions total). All patients start here regardless of funding.
Maintenance
1× per week or 1× per fortnight
Following induction. Frequency based on patient response.
Outside the standard schedule? If the dosing interval falls outside the above (e.g. every 10 days or every 3 weeks), a Schedule B application must be submitted before treatment continues.
TMS ACT  ·  SPRAVATO Doctor Initiation Guide  ·  For clinical use only