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0byt3m1n1
0byt3m1n1
Path:
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hermes
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bosweb
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web
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sb_web
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web
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web
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web
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web
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sb_web
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b1536
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commonsenseketamine.com
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[
Home
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File: page.html
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class="state-loading-desktop-viewer"> <div id="desktop-loading-screen"></div> <div id="body-element"> <header class="site-element" element-id="id1421251284921" element-type="HeaderElement"> <div class="element-children-container"> <div class="site-element" element-id="id1421591799515" element-type="image"><img src="https://storage.googleapis.com/wzukusers/user-32797362/images/5c91bb37abdaf0rlxOlN/vial.JPG" width="329" height="484"></div> <h3 class="site-element" element-id="id1421308840781" element-type="freeText"> <div><br></div> </h3> <h1 class="site-element" element-id="id1553054656221" element-type="freeText"><br></h1> <div class="site-element" element-id="id1421591966038" element-type="line"></div> <h2 class="site-element" element-id="id1421308832143" element-type="freeText"> <div><span style="font-size:42px;">Common Sense Ketamine</span><br></div> <div><span style="font-size:42px;"><span style="font-size:30px;"></span></span>How to use affordable ketamine in medical practice.<br></div> </h2> </div> </header> <div class="site-element" element-id="1407085040751" element-type="PageContentElement"></div> <section class="site-element" element-id="id1553054472986" element-type="SectionElement"> <div class="element-children-container"> <div class="site-element" element-id="id1553124234633" element-type="freeText"> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;">Last updated 3-25-2020<br></span></div> <div><span style="font-family:arial;"></span><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Recently the pharmaceutical company Janssen announced the availability of a ‘new’ treatment for severe depression that hasn’t responded to other treatments or medication. It is a brand name of esketamine called Spravato. As a psychiatrist I have been waiting for this for a long time. However I was incredibly disappointed to see that its use would be severely restricted to clinical settings, limiting how many people were able to manage the travel to access it. Of even greater concern is the price.<br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Writing for Forbes on 3-11-19 healthcare analyst Joshua Cohen wrote:</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">“Esketamine's wholesale acquisition cost will be between $590 and $885 per treatment session. That implies the list price of the drug for a month of treatment — which includes two sessions a week — will be between $4,720 and $6,785. This does not include the costs of physician visits and monitoring, which will be substantial given the high degree of monitoring required.”</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">This means that for anytime in the foreseeable future esketamine is out of reach for the vast majority of people that need it.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Fortunately, there is another option.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Spravato (esketamine) is actually just an isomer of ketamine. Ketamine is an anesthetic drug that has been studied from 2000 for severe refractory depression. Esketamine is just one of the mirror image molecules that are already part of regular ketamine. But since regular ketamine is generic no company can make a lot of money with it anymore. However by separating out part of the ketamine into the isomer esketamine, pharmaceutical companies can get an exclusive patent to sell it at any price they choose. However only esketamine can be advertised for depression since the FDA has never issued an approval (indication) for depression for generic ketamine.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">What that means is that regular ketamine, the one that the initial research trials found so helpful and directly led to isolating esketamine, is perfectly capable of being used for depression.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">While Spravato (esketamine) costs $5000 a month, you can still get regular ketamine for about $50 a month. Doctors just haven’t thought enough about how to do that.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">I’ve used ketamine orally for over 7 years now with about 50 patients without major problems and fantastic results for their refractory depression. This website is designed to share what I’ve learned. Most of my patients take the medication by mouth diluted in water from the pharmacy. Recently I have used injections in a couple of patients that I thought were not getting a complete response with excellent results.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">For anesthesia you would have to give a couple hundred milligrams IM/IV. There is no respiratory suppression with ketamine which is why the third world uses it so much because you don't need an anesthesiologist for procedures. Of course veterinarians use it every day in animals safely. It is very difficult to find deaths associated with ketamine even in ketamine addicts that are snorting a gram every day. Ketamine was not even a controlled substance from the time it came out (early 1970’s) until 1999 when it gained the unfortunate reputation of being a ‘club drug’ (special K) that most people still associate it with. The biggest problem with long-term use of ketamine that I’ve found in the literature is bladder irritation in some case reports of addicts using up to 1000mg a day. I don’t know if that was street ketamine or pharmaceutical grade. Truthfully I worry more about my patients taking NSAIDs in terms of long term problems. Obviously the potential benefits of using ketamine should outweigh any potential risks for using it, but that's usually a straight-forward thing for refractory depression or certainly patients with chronic suicidality.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">I have never seen any evidence of tolerance or diminished effectiveness even with patients taking ketamine every day for years.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-size:30px;"><span style="font-family:arial;"><br></span></span></div> <div><span style="font-size:30px;"><span style="font-family:arial;">1.)Most people will get a good response to ketamine just by drinking it.</span></span><br></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Until Spravato, ketamine was usually only used in a clinical setting as an intravenous (IV) infusion that people would pay several hundred dollars for and wasn’t covered by insurance. The effects lasted a few days or maybe a week. The price and inconvenience of an IV practically guaranteed patients would relapse back into depression before their next IV treatment. But by getting it and using it orally, intranasally or even intramuscularly patients can get ketamine at their pharmacy like any other drug and use it at home. And with regular dosing at home there is no relapsing between treatments like there is intravenously and at a much, much lower cost.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Ketamine is not a first line antidepressant due to cost, availability and the potential for abuse. It is used for cases of depression that have not already responded to at least several conventional antidepressants.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Most of my patients will respond by taking a lower dose of ketamine by mouth (orally) than they would ever get intravenously. For oral ketamine the standard dose I use is 10mg every day or every other day by mouth. By comparison when ketamine is used for anesthesia an adult patient (say one who weighs #180lbs or about 82 kilograms) might get over 300mg intravenously for a duration of 10 minutes of anesthesia followed by additional ketamine for longer procedures. If the anesthesia was done with an injection intramuscuraly (IM) it might take over 700mgs of ketamine plus.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">A dose of 10mg ketamine is far too low to ever induce anesthesia in an adult, but for many people it is all they need for a good antidepressant response. Another factor to consider is that given orally most of the ketamine (about 80%) is destroyed by the liver leaving only about 2mg of ketamine active in the body (known as bioavailabilty). </span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">The bioavailability of the oral route is 20% vs. 90% for intramuscular (IM) vs. 25-50% intranasal vs. 100% intravenously (IV) due to the first pass metabolism in the liver. At the 10mg oral dosage the biggest problem I have ever seen is a very slight dizziness that may last 15 to 20 minutes. I have patients take their first dose in my office and then wait 45 minutes in my waiting area in case of problems. No one taking 10mg orally has ever been impaired enough that they couldn’t drive or interact normally. Usually after the first couple of oral doses patients no longer report any side effects. I still recommend taking it at bedtime. The time for response is generally 20 minutes to 24 hours. The beneficial effect usually lasts 2 - 7 days per dose. The response is clear and obvious (in some cases dramatic). My results with the oral route of administration seem comparable to the IV route of administration for most patients. </span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div> <u><em><span style="font-family:arial;"><span style="font-size:18px;">Prescription written for a 4 week (30 days) supply of oral ketamine:</span></span></em></u><br> </div> <div><span style="font-family:arial;"><span style="font-size:18px;">Ketamine 300mg </span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">mixed in 1 liter plain water</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Sig: take 34ml po qd or as directed for refractory depression</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">(This is a 30 day supply of 10mg ketamine per day)</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">For my patients that are stable I will give a 3 month supply - the advantage to this is that only 2 vials of ketamine are required to yield 3 months of medicine and the price is around $55. The patients will get 3 one-liter bottles from the pharmacy at a time. Recently the compounding pharmacy I use has found it cheaper to mix ketamine powder with bottles of 1 liter sterile water they keep in stock.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><em> <u><span style="font-family:arial;"><span style="font-size:18px;">Prescription written for a 12 week (90 days) supply of oral ketamine:</span></span></u> </em><br> </div> <div><span style="font-family:arial;"><span style="font-size:18px;">Ketamine 900mg</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">mixed in 3 liters plain water</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Sig: take 34ml po qd or as directed for refractory depression</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">(This is a 90 day supply of 10mg ketamine per day)</span></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><span style="font-size:30px;">2.) You can take it nasally</span><br></span></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">For patients who do not respond to taking ketamine orally, they can take it intranasally similar to Spravato (esketamine). Patients can be started at 1 spray in one nostril (5mg depending on the concentration of medicine and how much the sprayer delivers) and increased by a single spray every couple of days until response.<br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div> <u><em><span style="font-family:arial;"><span style="font-size:18px;">Prescription written as:</span></span></em></u><br> </div> <div><span style="font-family:arial;"><span style="font-size:18px;">Nasal Spray:</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Ketamine 50mg/ml</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">#10ml in nasal pump</span><br></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Sig: use (1-7) sprays (0.1ml/spray) per nostril q 2-5 days for refractory depression as directed</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">(1-7 sprays of ketamine in each nostril is 10 to 70mg of ketamine if using the injectable solution of 50mg/ml)</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:20px;"><br></span></span></div> <div><span style="font-size:30px;"><span style="font-family:arial;">3.) For people who fail the oral and nasal routes it can be given as an intramuscular injection.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">I have in several cases used intramuscular (IM) injections of ketamine when the oral and intranasal routes haven’t worked. In those situations the IM worked for a more complete response than the intranasal. Of course patients need to be reliable and capable of injections at home if this route is to be used and the benefits should always outweigh the risks. Ketamine does have an abuse potential and can give an hallucinogenic event at higher doses. It is not an opiate like most painkillers.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">A single test dose in the office is sufficient to see if they will respond and the events can be monitored as some people will report dizziness that requires them to wait quietly for 10 to 20 minutes. I have seen responses from IM injections in as little as 3 minutes to 24 hours.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">I try to avoid IM injections, but I can’t deny the dramatic improvement in several of my patients. If patients are reliable enough they can be given prescriptions for injectable vials of ketamine plus needles and syringes that can be filled at a compounding pharmacy willing to stock it. Finding a pharmacy willing to stock it is probably best done by the physician arranging an in-person meeting with a compounding pharmacist. Compounding pharmacists are already familiar with using ketamine in topical pain creams but providing them with research articles may go a long to making them comfortable to stock ketamine. Maintaining good relations with a pharmacy and insuring that the physician only sends the pharmacy reliable patients is very important.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Ketamine is a schedule III controlled substance by the DEA, which does not have the additional regulation of opiates and psychostimulants that are schedule II.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"><br></span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">I have 2 patients that have previously had IV infusions of ketamine at other places. Both thought the IM injections were equivalent to their IV infusions. One I was able to transition to the intranasal route. I suspect that due to the small difference in bioavailability of IM vs. IV ketamine (90% vs. 100%) most patients receiving IV ketamine would do fine on IM injections which would be much less expensive $50 to $100 a month for IM injectable vials vs. single IV infusions that can cost up to $600</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">For chronically depressed and suicidal patients ketamine can be potentially life saving. We use other antidepressant treatments like tricyclic antidepressants, lithium and electroconvulsive treatmet (ECT, formerly called electroshock) that can be much more dangerous, expensive or difficult to access already. Doctors are understandably cautious about ketamine due to its abuse potential but this can be managed just as we already do for benzodiazepines (Xanax, Klonopin, Valium) and ADHD stimulants. </span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><span style="font-family:arial;"><span style="font-size:18px;">Patients can be taught to give themselves ketamine injections at home just like we do for diabetes or B12 deficiencies. There is no reason a ketamine should be any different in the right patient.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Doses for IM ketamine in patients that had only partial response to oral and intranasal ketamine tend to be higher, perhaps 20 to 50mg a day. These patients should arrange for their doses before bed when side effects would be less likely to cause problems. They should not drink alcohol before dosing to avoid magnifying side effects.</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"> <u><em></em></u> </span> </span><br> </div> <div><span style="font-family:arial;"><span style="font-size:18px;"> <u><em>Prescription written as:</em></u><br> </span> </span> </div> <div><span style="font-family:arial;"><span style="font-size:18px;">IM injection:</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Ketamine 50mg/ml inj. sol.</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">#1 vial of 10ml</span></span></div> <div><span style="font-family:arial;"><span style="font-size:18px;">Sig: 0.2 ml (10mg) IM injection q 2-5 days for refractory depression</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;">(the above script would amount to about 50 doses or almost 2 months a vial, some patients will require multiple vials based on their dose)</span></span><br></div> <div><span style="font-family:arial;"><span style="font-size:18px;"></span></span><br></div> <div><span style="font-family:arial;"><br></span></div> <div><span style="font-family:arial;"><br></span></div> </div> </div> </section> <footer class="site-element" element-id="id1421308881485" element-type="FooterElement"> <div class="element-children-container"> <div class="site-element" element-id="id1421308881486" element-type="freeText"><br></div> </div> </footer> </div></body> </html>
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