How many types of ketamine are there? There are different forms of the ketamine molecule and different ways to administer treatment.
First, we should acknowledge the different forms of the ketamine molecule. For about 50 years, we have had one form of ketamine that has been approved by the FDA for medical use.
This time-tested ketamine is known as a racemic mixture. It contains both the right and left-handed forms of the ketamine molecule, also known as the r and s isomers.
In recent years, scientists have studied the individual R isomer and S isomer of ketamine. S-ketamine, also known as esketamine, is currently approved by the FDA for treatment-resistant depression.
Eskatamine is also known by the name, Spravato, and it is only available as a weekly nasal spray. Did the scientists who studied these stereoisomers of ketamine determine that esketamine works better than racemic ketamine?
Some mental health experts believe that the reason esketamine nasal spray was approved as Spravato was a tactic to create a new ketamine brand that could be protected by a drug patent. Since racemic ketamine has been around for half a century, it is off-patent, so big pharma cannot make big profits off of it.
Which ketamine types are most effective?
In fact, there are doctors who have worked with ketamine for decades who believe that racemic ketamine is more effective than esketamine for treating depression, and many other conditions. If this is true, why would a patient seek Spravato treatment?
One reason to prefer Spravato, or intranasal ketamine, is that health insurance plans often cover treatment where they will not cover any treatment with racemic ketamine, since most use is considered to be off-label. When you go to a ketamine clinic, IV ketamine infusion therapy is typically not covered by insurance, but the Spravato nasal spray is covered.
Now that you know about the left-handed ketamine molecule, esketamine, what about the right-handed molecule? What about R-ketamine? Is it also effective in treating depression?
There have been studies involving R-ketamine. Some experts believe that R-ketamine may be even more effective for treating depression than S-ketamine.
Some evidence points to the possibility that the effects of R-ketamine may be longer lasting. Also, the psychedelic, mind-altering effects are less prominent, which may be desirable for some patients.
Traditional ketamine intravenous therapy uses racemic ketamine.
When we look at the three dimensional structure of the ketamine molecule, we see there are three types of ketamine, the R and S isomers, and the racemic mixture of both stereoisomers. Racemic ketamine is the traditional compound that has been around for decades, and is the predominant form of the drug used for IV treatment.
The best treatments for depressive disorder utilize ketamine infusions. The patient receives an IV infusion of racemic ketamine, meaning they get both R and S isomers blended together. The IV treatment delivers an effective dose of the complete form of ketamine, not just one isomer or the other.
Additionally, ketamine infusion has another major advantage over intranasal esketamine. Infusion therapy works for many more conditions besides depression. Spravato can only be used for depression symptoms where antidepressant medications did not work.
IV ketamine treatment is a full psychedelic therapy, similar to psilocybin, but ketamine is legal and has been in use as an approved medication for many decades. Not only does it provide an antidepressant effect for severe depression, it works for chronic pain, post traumatic stress disorder, suicidal thoughts, anxiety disorder, and other mood disorders and mental illness, such as bipolar disorder.
Due to its activity at the NMDA receptor in the brain, ketamine is ideal as a depression treatment, significantly reducing depressive symptoms, and it works for many other mental health conditions. For the patient who wants to get the Spravato nasal spray, they must have been diagnosed with clinical depression, but for ketamine IV infusion therapy, there are many more diagnostic options.
What forms of racemic ketamine are there?
Again, when we refer to racemic ketamine, we are discussing the medication that has in use in hospitals and clinics for about 50 years. We most often simply refer to it as “ketamine,” but now, we must differentiate it from drugs such as Spravato, and other isolated stereoisomer derivatives.
The best known brand is Ketalar, which is available as a generic, and it comes as a liquid suspension in a sterile vial. This is the familiar form of the drug used in clinics for IV infusions.
In addition to infusion therapy, ketamine can also be administered intramuscularly, or IM. The effects, and results, are similar, but it is not quite as precise a therapy as IV.
When ketamine is administered via IV, the healthcare professionals managing the therapy can be very precise in dosing and timing. Intramuscular therapy, on the other hand is like getting a shot in the arm, or in the butt. The medicine goes in, and the effects last until it wears off.
Sublingual tablets or troches are another option. Ketamine is not active as an oral medication, but it does work when dissolving it under the tongue. This form of administration is still less precise than IV or IM, but it does not involve any needles.
There are different ketamine options to meet the needs of individual patients.
Most of the medication is not absorbed sublingually, so the dosage of the tablet or troche must be more than what would be given in an IV infusion or IM injection. Some clinics offer sublingual therapy as an option to avoid needles. The patient is given medical therapy and observed in the same way, but they simply dissolve the medication under their tongue.
Another less commonly used form of the drug is the ketamine suppository. A suppository is administered rectally, either by a nurse or self-administered by the patient. Absorption may be similar or better compared to sublingual.
Suppositories may be ideal for patients who do not like needles, but they also cannot tolerate the taste of the sublingual medicine. There are also a variety of reasons why a person cannot tolerate oral medication, such as nausea, mouth pain, or inadequate saliva.
What is the best form of ketamine for any mental health condition?
As mentioned before, ketamine has been around for a long time. It has been used for many years in hospitals and outpatient clinics as an anesthetic. Doctors prefer it in many cases because it is both highly effective and very safe.
Since the drug has been used so widely over decades, doctors and scientists have had the opportunity to study it carefully, learning about the unique brain-healing effects. They have discovered many uses for ketamine treatment that rely on the effects that ketamine has on the brain, including an anti-inflammatory effect and a dendritic growth effect, where connections between brain cells increase and improve.
At this time, most ketamine experts would agree that IV therapy is the ideal form of treatment. The patient is getting the therapeutic benefit of racemic ketamine, which includes both the S and R isomers. Some experts believe that part of the therapeutic benefit lies in the psychedelic aspect of the treatment, which occurs at higher dosages.
In order to safely administer an adequate dosage for the optimal experience, IV ketamine therapy is ideal, because the healthcare professional is able to precisely control the patient levels of ketamine in their system. During and after treatment, the patient can work with an integration therapist to put together and make sense of new understandings gained during ketamine treatment.
In most cases, the answer will be intravenous ketamine therapy.
In addition to working for migraines, bipolar disorder, OCD, PTSD, depression, anxiety, chronic pain, suicidality and more, ketamine IV infusion therapy also works well for addiction. One particular addiction that responds very well is alcoholism.
Ketamine helps the alcoholic to avoid relapse for much longer stretches of time, allowing the person to work on their foundation for recovery. In addition to alcohol use disorder, ketamine helps patients addicted to opioids to make transitions to medical treatment by reducing opioid withdrawal symptoms and cravings.
For now, we must conclude that ketamine IV infusion therapy is the ideal form of treatment in many cases. Though, there are specific situations where a different form of administration might work best, and some patients with depression may prefer to try Spravato nasal spray therapy.
To learn more about the best ketamine treatment Maryland has to offer, please contact us. We would love to help you learn more about the options available, including various forms of ketamine treatment as well as combined ketamine and TMS therapy.