Which is better? Ketamine or Spravato?
Are you wondering which is better: Ketamine or Spravato? You are not alone. Spravato (Esketamine) is a new drug produced Janssen Pharmaceutical and is the first new method to treat depression in over 25 years. On March 05, 2019, the US Food and Drug Administration (FDA) announced that Spravato was approved to treat patients who suffer from treatment resistant depression (TRD). In many ways, this is a great step forward in discovering better ways to treat depression, but we still have much to learn.
How Spravato Works
Spravato is a nasal spray medication that works in conjunction with a patient's oral antidepressant. It is also the new recommended treatment method for patients who have struggled with depression and have tried multiple antidepressants but failed to find adequate relief.
During the main clinical trial for Spravato, those who took Spravato along with their oral antidepressant experienced a greater reduction of depression symptoms at four weeks compared to those who received a placebo plus an oral antidepressant. Moreover, many patients experienced some relief within 24 hours.
As a practitioner, it is my objective to give my patients the very best clinical advice that I can offer. In my opinion, I think Ketamine will oftentimes be the better option for patients over Spravato--and here is why: Research has shown IV ketamine to be more effective than nasal esketamine.
In a recent article by science reporter Olivia Goldhill, she addresses a question many physicians are asking: "why ketamine, [esketamine’s] better-known and cheaper cousin, is not being similarly developed."
Ketamine has a proven history
Ketamine has a long and more proven history with much more research supporting its use. Even though it is not FDA approved to treat depression, patients can be treated “off-label.” Ketamine research has been mounting since 2006 and the benefits that ketamine provides to patients with depression, PTSD, anxiety, and chronic pain are becoming more and more evident, and as Goldhill points out “are increasingly recognized by mainstream medical centers.”
In Goldhill's article, Michael Alpert, a psychiatrist at Harvard Medical School is quoted saying, “Regular ketamine is safe, available in multiple different formulations, has demonstrated efficacy in multiple small-scale studies for treatment-resistant depression, and is available for a fraction of the cost of esketamine because it’s been off patent for decades.” Turns out that Ketamine’s patent expired in 2002, and therefore further studies were abandoned because funding companies recognized they would not see significant financial returns on the drug.
Long story short, the solution was to simply isolate one of the components of regular ketamine (esketamine), patent that, and then put that drug into clinical trials for FDA approval. And that is exactly what happened. In fact, the FDA granted Janssen Pharmaceutical's application Fast Track and Breakthrough Therapy designations.
The problem here is that while Spravato demonstrates more immediate relief in some cases, it does not necessarily translate into better long-term benefits for patients, and in some cases it appears to worsen symptoms. In fact, according to a story published by inewsource, evidently the VA Healthcare System in San Diego “abruptly prevented all patients from taking ketamine via IV and pushed them to take esketamine at a different clinic” and the result was that several veterans actually suffered worsening depression.
According to some experts, Spravato appears to be beneficial in an emergency situation, such as if someone is admitted to the hospital with suicidal thoughts. Currently, in order to begin treatment with Spravato, a licensed provider must order the nasal spray for you and pick it up on the day of your treatment. Patients can work with their insurance to submit a claim. When patients arrive for their appointment, the patient sprays each nostril (with the provider present), and then must be monitored for 2 hours at the clinic. There is an additional fee for monitoring, which must be paid upfront, and then the patient is responsible for submitting all claims to their insurance company. The drug is to be administered 2 times per week for 4 weeks, then 1 time per week for another 4 weeks and then tapered to every other week, or weekly depending on the patient’s response.
Consideration for Spravato
With that being said, this is what you have to consider when deciding between Spravato and Ketamine. If your insurance covers the cost of the drug and reimburses you for the clinic monitoring time, then Spravato may be right for you. However, if your insurance only covers a part of the above, it is advised that you weigh that against:
a. The cost of the IV ketamine treatments
b. The time it takes to do IV ketamine versus nasal (1hr versus 2hrs)
c. Research has shown IV ketamine to be more effective than nasal
As a provider of both Ketamine and Spravato, I want my patients to have a choice, and to have access to the best information available to help them make the most informed decision about which treatment method to pursue.