Ketamine nasal spray: all about esketamine
What are esketamine and Spravato™?
Recently, the FDA approved ketamine nasal spray for depression treatment, more specifically an intranasal version of Ketamine’s “mirror molecule”: esketamine.
It is patented under the name Spravato™ by Janssen Pharmaceutical.
Esketamine vs Ketamine: what is the difference?
These terms: Spravato, esketamine and ketamine are commonly confused or used interchangeably.
Molecularly speaking, there are two isomers, S and a K, that comprise Ketamine.
When clinics refer to administering Ketamine, they are talking about a “racemic mixture.” This term denotes a combination of S and K.
Esketamine, brand name Spravato, is the S isomer of the molecule.
To clarify, Ketamine therapies use a combination of S and K molecules. Esketamine intranasal spray only uses the S side.
Therefore, these are NOT the same thing.
Accordingly, different isomers or combinations have other properties and side effects.
The S is known for x and y. The K is known for x, y. What we call Ketamine in a clinical environment is the mixture, and it is known for x and y
It is essential that in both clinical and research settings, the specifics of these variations are acknowledged.
Are esketamine and Spravato™ FDA approved?
In 2019, Ketamine’s “mirror” molecule, “esketamine,” was approved by the FDA for Treatment-Resistant Depression (TRD).
The brand name of esketamine is Spravato™ and is an intranasal spray, not an infusion.
Esketamine treatment: can I use esketamine or Spravato™ at home?
The regulations for the use of Spravato™ are in flux.
We receive reports of the nasal spray offered in Ketamine clinics, other types of clinics (i.e., psychiatric), and for use at home.
Some at-home patients take esketamine as a maintenance tool in between ketamine infusions.
As experience with and study of this drug and its delivery mechanism increase, how and where it should be used will be more defined.
Do clinics offer the esketamine nasal spray Spravato™?
Some Ketamine clinics do prescribe intranasal Spravato™ esketamine spray as a treatment option.
However, Spravato™ is relatively new, with FDA approval from 2019.
Ketamine infusions have a six-decade history of safe and effective use.
Ketamine infusion vs nasal spray: Is Spravato better than IV Ketamine?
Studies of Spravato / esketamine are few. The use of Ketamine via infusion has a long, 60-year history.
Ketamine IV therapy is applied to a wide variety of conditions and in a controlled setting. Whether esketamine nasal delivery is as effective as ketamine IV is unclear at this early date.
Some physicians are raising concerns about complicating variables regarding treatment with esketamine vs. ketamine, specifically due to the delivery mechanism.
Given the significant reduction in the bioavailability of intranasal delivery, is achieving therapeutic doses realistic?
What is the proper dose across conditions? (not only depression)
Does this also vary from person to person due to sinus surface area or airway status (inflamed or stuffy nose, for instance)?
Is the initial dose determined by weight (as it is for infusions)?
How should the dose be distributed over time? With ketamine nasal spray applications, the patient sniffs the drug all at once. With Ketamine infusions, the dose is spread out over time, commonly not less than 40 minutes and as much as several hours.
Does the drug follow a different cascade of reactions because of the nasal vector?
Is metabolism and clearance achieved through the same organs we see with Ketamine? If not, how does this impact the side effect profile or introduce new contraindications?
IV Ketamine infusions benefit from a long history of use in many settings, from the battlefield to the Emergency Department and surgical and psychiatric settings.
Ketamine and esketamine nasal spray cost
Why are Ketamine treatments so expensive?
The IV version of Ketamine is not under patent and is surprisingly inexpensive. High therapy session costs stem from the infrastructure of running a clinic, including leasing office space, liability insurance, staff, and equipment.
Does insurance pay for Ketamine infusions and esketamine nasal spray?
Classified as “experimental,” Ketamine is not officially approved for use outside of anesthesia and pain relief. Only the esketamine version is approved for treatment-resistant depression.
Insurance is not required to cover experimental applications. As a result, it can be difficult to secure insurance reimbursement. This also means that patients are required to pay upfront and attempt reimbursement through their health insurance on their own.
Esketamine / Spravato is covered by insurance for treatment-resistant depression.
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Does the pharmaceutical company for Spravato offer discounts?
The intranasal version of esketamine, called Spravato™, might come with financial assistance.
What form of Ketamine therapy does Frank receive?
I receive IV Ketamine infusions. I’ve not tried esketamine intranasal spray.