IV vs Intranasal Ketamine: Which is Better?

Intravenous ketamine and intranasal esketamine are both equally effective in improving symptoms of treatment-resistant depression (TRD) in adults, but \”speed and cost\” appear to favor IV ketamine in clinical practice, as the results of one study show. single center observational study.

Because of insurance restrictions on esketamine nasal spray, initiation of treatment can take several weeks longer than with IV ketamine. Additionally, the cost to get the same clinical benefit is about six times higher for esketamine vs ketamine, said study investigator Thomas Scott, MD, with Scott Integrated Pain Management, Philadelphia, Pa. Medscape Medical News.

Scott and co-investigator Blake Gilbert-Bono, BA, MS2, University of Pennsylvania Perelman School of Medicine, Philadelphia, presented the study at the 2023 American Psychiatric Association (APA) Annual Meeting.

Let patients decide?

Both ketamine and esketamine have been shown to have rapid antidepressant effects in adults with TRD.

Using patient-level data, the researchers compared the effectiveness and cost of the two drugs in a real-life setting.

Among 89 TRD patients treated at their clinic, 19 were treated with intranasal esketamine at an initial dose of 56 mg, up to a maximum dose of 84 mg, and 70 were treated with IV ketamine at an initial dose of 0 .5 mg/kg adjusted for body weight, up to 1 mg/kg. All patients also received an oral antidepressant.

At each treatment, patient mood was assessed using the Quick Inventory of Depressive Symptomatology Self Reported (QIDS-SR) scale. Suicidality was also assessed with each treatment on a binary scale.

Scott said comparisons of all efficacy endpoints revealed \”no reliable or statistically significant differences\” between nasal esketamine and IV ketamine.

Based on the analysis, patients \”should expect a relatively rapid reduction of 5.57 QIDS points in the first 6 treatments (3 weeks) of using either drug,\” the researchers note.

Furthermore, among the 44 patients who initially presented with suicidal ideation, no differences were found between the two drugs in terms of reduction of suicidality. Furthermore, there was no significant difference in the side effect profile between the two drugs.

However, the researchers calculate that the cost of intranasal esketamine is about six times that of IV ketamine. Also, due to insurance restrictions for esketamine, it can take \”several weeks\” longer to start treatment than for ketamine, Scott said.

\”In my practice, I give patients the choice\” of intranasal esketamine or IV ketamine, she said.

“An advantage of IV ketamine is that I can usually start treatment faster and patients are usually eager to start. Sometimes it takes longer to start esketamine because we have to enroll them in the REMS program,” Scott added.

Support Data, large RCTs needed

Commenting on the study for Medscape Medical NewsGerard Sanacora, MD, PhD, professor of psychiatry, Yale School of Medicine and director of the Yale Depression Research Program, New Haven, Connecticut, said the results of this study are \”interesting\” and similar to a recent publication by his team.

In the Yale study of 210 TRD patients, both IV ketamine and intranasal esketamine were shown to help relieve symptoms of depression.

However, there are \”some major problems with this report, like there were with our report,\” Sanacora said.

The study was not randomized, \”so it is likely that the patients were receiving one treatment or another due to some other factor\” such as insurance coverage or personal preferences.

\”This means that there is likely to be some form of bias in the sampling of the two groups. We just don\’t know how strong an effect that bias has on the outcome.\”

\”That\’s my main concern and it really argues that we need to do a real randomized controlled trial,\” Sanacora said.

The study did not have specific funding. Scott e Gilbert-Bono reports no material financial dealings .

American Psychiatric Association (APA) 2023 Annual Meeting: Poster P12-007. Presented on May 23, 2023.

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