IV vs Intranasal Ketamine: A Professional Guide

If you’re an adult with treatment-resistant depression (TRD), you’ve likely heard of two treatment options: intravenous (IV) ketamine and intranasal esketamine. Both are effective, but factors like “speed and cost” might make IV ketamine more appealing. This guide will help you understand these aspects for a more informed decision.

The Study: Comparing IV Ketamine and Intranasal Esketamine

This information is based on a study by Dr. Thomas Scott from Scott Integrated Pain Management, Philadelphia, and Blake Gilbert-Bono from the University of Pennsylvania Perelman School of Medicine, Philadelphia. They shared their findings at the American Psychiatric Association (APA) 2023 Annual Meeting.

The study involved 89 TRD patients — 19 treated with intranasal esketamine and 70 with IV ketamine. All patients also received an oral antidepressant.

Evaluating Efficacy and Cost

The researchers used the QIDS-SR scale to measure patient mood at each treatment and assessed suicidality on a binary scale. They found no significant differences between nasal esketamine and IV ketamine in terms of efficacy.

Key findings:

• Both treatments offer rapid antidepressant effects.
• You can expect a quick reduction of 5.57 points on the QIDS scale within the first six treatments (or three weeks) using either drug.
• Among the 44 patients who initially presented with suicidal ideation, no differences were found between the two drugs in reducing suicidality.
• There was no significant difference in the side-effect profile between the two drugs.

The Impact of Cost and Insurance Restrictions

While both medications are effective, their cost and insurance restrictions might influence your choice. According to Dr. Scott, esketamine treatment can take several weeks longer to initiate than IV ketamine due to insurance restrictions. Plus, the cost of achieving similar clinical benefits with esketamine is roughly six times higher than with IV ketamine.

Making Your Choice

Dr. Scott believes in giving patients a choice between intranasal esketamine and IV ketamine. He noted that IV ketamine treatment can usually start faster, often preferred by patients eager to begin their treatment journey. Starting esketamine treatment might take longer due to registration requirements in the REMS program.

Future Research Needed

Gerard Sanacora, MD, Ph.D., professor of psychiatry at Yale School of Medicine, pointed out that this study is not randomized. This means patients might have chosen one treatment over the other due to factors like insurance coverage or personal preference, potentially introducing bias. He suggested that a true randomized controlled study needs to be conducted for more definitive answers.

In conclusion, both IV ketamine and intranasal esketamine have their merits. When weighing your options, consider not only their efficacy but also the cost, waiting times, and potential insurance restrictions. Always consult with your healthcare provider to decide which option suits your needs best.