Esketamine. Where we at?

Between the TODAY show, CNN, The Washington Post, etc. those of you that follow us are probably wondering, how soon can we start???

First, I am so happy that you are so excited because the impact of depression on lives is crippling. Any of us who struggle personally or see loved one’s suffering know that WE ARE READY!!! Let’s jump in right? Well, hear me out. I promise I am not going to “hate on” Esketamine, I just want to explain a few things.

Those of you who are having ketamine infusions are already getting S-ketamine (see what the drug company did there? The name of the drug is the name of the left-handed enantiomer of ketamine).

Medications are chemical compounds. These chemical compounds often exist as 2 enantiomers (a right handed or “R” and a left handed “S”). If the medication has both enantiomers (the “R” and the “S”) included in the formulation it is considered racemic. So, a regular vial of ketamine, the drug that has been around since the 1970s, is a racemic mix of both “R” and “S” ketamine. Johnson & Johnson (the makers of Esketamine) has separated the “R” from the “S” ketamine. Exciting because there is some evidence that “S” ketamine may have less side effects than a racemic mixture, is seen as a new drug so can/has gotten FDA approval which means insurance will most likely cover it, and the intranasal aspect makes it more accessible to patients. Is this a NEW miracle drug? No. BUT allowing increased accessibility to patients is a BIG deal to us (not just Thrive but all your healthcare providers).

Money talks, right? So, if this is covered by insurance this means my treatment will be cheap, right?

Honestly, right now, I don’t know. I don’t think any of us providers know. What we do know is this:

The list price of the drug will be $590 to $885 per treatment session based on the dosage taken, which will vary between patients. During the first month of therapy, that would add up to a price in the range of $4,720 to $6,785. After the first month, maintenance therapy could range from $2,360 to $3,540.” The Washington Post

We don’t know how much of this cost insurance will cover, and if they do cover the drug itself will they also cover the 2 hours of monitoring after? The North Dakota Board of Nursing has made a statement regarding who can monitor patients during ketamine administration. This changes cost of monitoring. Will this even matter since it is “S” ketamine instead of racemic ketamine? I don’t know.

Because of the high cost of “S” ketamine and because it is already included in the much less expensive vial of racemic ketamine will that mean insurance will start covering racemic ketamine as well to keep costs down? I have no idea. I hope! For a patient without insurance coverage, “S” ketamine is much more expensive than regular ketamine IV. The crazy part, depending on what you are being treated for “R” ketamine may be more beneficial to you than “S” ketamine so using a racemic mixture allows us to cast a wider net.

I really don’t want to hate on anyone. Drug companies need to make money in order to have clinical trials which help keep us all safe. Fiscally, it is almost impossible take a drug that is generic and proceed through clinical trials as you can’t make up the money. I am certainly not an expert on this process, but I experience the frustration of marketing a “new drug for depression” that is technically part of a drug we have had since the 70s.

Esketamine is certainly less invasive (intranasal instead of IV) and should thus be less time, right?

Let me start with the intranasal part. I get it. I hate being stuck with needles as much as you (I actually RAN around a medical office once avoiding a vaccine, mind you I was in MIDDLE SCHOOL!!!). But here is the concern with intranasal delivery… your nasal mucosa changes constantly. Remember that cold you had last month? Your drug absorption of intranasal products will decrease when you have the sniffles. Have chronic post nasal drip and sinus issues like me? Intranasal might be tricky to get you the right dose. With intravenous, we know how much of the drug you are getting EVERY SINGLE TIME. 100%. Obviously, there are many drugs that can be given intranasally and work well and I really hope this is one of them. These are just concerns, not deal breakers, in my opinion.

Time is money right!? A normal IV infusion of ketamine for depression in our office is scheduled for 90 minutes. That includes time for IV start and recovery. Of course, as every patient is an individual and sometimes require longer infusions or longer recoveries, but this is just our general time frame. Esketamine is still going to require an office visit for administration and then a 2-hour monitoring window following. Our policy will require you needing a driver to pick you up after the recovery period (in the same as it is now). The time, in my opinion, the least concerning factor but I thought I would bring it up.

The best part of this whole situation is it will now be more difficult for insurance companies and other providers to claim that ketamine is not effective to treat depression. That is a HUGE step for all patients in order to get access. Please understand that although this is a wonderful medication (we built our business on it!) it is NOT magic and the way to get the best results is to work WITH your mental health provider and us. In the role of mental health, we at Thrive are more the technicians while your mental health provider is the home base. Diet, sleep and nutrition are also important aspects of your wellness that no drug can replace.

Are you a provider that wants the nitty gritty? Contact us and we can send journal articles about Esketamine, ketamine for chronic pain, ketamine for depression etc. We like to share. info@thriveanesthesia.com

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