Esketamine Nasal Spray from Lori Calabrese, MD | The Ketamine Blog

We provide these articles about esketamine nasal spray, known by the brand name Spravato, to inform… and explain the similarities and differences between esketamine and ketamine, the compound esketamine was derived from. 

Racemic Ketamine and Its Twin Molecules

As a compound made of two mirror-image molecules, racemic ketamine performs with extraordinary and robust antidepressant strength. We call those mirror-image molecules enantiomers. So, the word “racemic” simply means a compound made of right-handed and left-handed molecules.

You probably notice that identical twins look not so much exactly the same, but rather, they look like mirror images of each other. This phenomenon occurs all through nature. And you see it on the cell level, too.

The fact that these molecules are mirror images of each other doesn’t mean they’re identical.  They’re similar…and have similar properties. Sometimes you see this with identical twins. For instance, one twin shows empathy, compassion, and introversion, while the other fills a room with laughter and friendliness.

In the same way, these molecules act differently also, with one showing stronger properties of one kind and the other showing stronger properties of another. It’s the synergy between the two that creates the characteristics of the full racemic compound.

The ketamine compound dynamically illustrates this. Each enantiomer behaves in some ways like the other, and behaves differently from the other in other ways.

We recognize the left enantiomer molecule s-ketamine…”s” being an abbreviation for the latin term for “left.” We recognize the right one r-ketamine, which is much easier to remember, right? So, with this in mind, they created a name that uses the “s” or the “r” phonetically.  So these enantiomers enjoy the nicknames of esketamine and arketamine. Clever-ish…maybe?

Creating a NEW Medicine with an Old Molecule

Researchers hoped that by separating the left mirror-image molecule from the right-side one, they could produce an antidepressant with fewer side effects and less addiction risk. They knew they needed an entirely new compound. Because they needed the financial benefits of a patent to pay for the extensive research and testing that would be required to receive FDA approval.

It turned out that their new medicine required the aide of a newly initiated anti-depressant to perform as an antidepressant effectively. But with that antidepressant added, it showed some promising ability for erasing suicidal thinking and lifting depression. 

Unfortunately, life in the laboratory behaves a lot like life everywhere else. It can be unpredictable. During the trials required for FDA approved, esketamine performed like a champ in some trials, and failed rather miserably in others.

At a time when the suicide rate rises higher and higher, psychiatrists need medicines that erase suicidal thinking. As a result, the FDA approved this new medicine along with its specially designed spray in March 2019. They took precautions, however.

They imposed safeguards. One such safeguard required that doses be restricted to administration in the office under medical supervision. Another one required that the doctor hold the patient for observation in the office for 2 hours after each dose, in case of side effects.

 A Ketamine-Derived Medicine Covered  by Insurance?

Janssen, a company owned by Johnson&Johnson which developed this medicine, promises that esketamine nasal spray will be covered by insurance. So, we’re waiting to hear what the coverage will be.

Will Spravato replace IV ketamine treatment?  Probably not.

While esketamine may not be as effective as ketamine and is more expensive to administer. Does it have a place in treatment of depression and suicidal thinking? We certainly hope so. The fact that insurance companies plan to provide coverage for it will hopefully make it available to patients who find IV ketamine treatment is out of reach financially.

Because of the way the media promoted Spravato (esketamine), most people think that ketamine nasal spray was approved by the FDA.  Esketamine isn’t ketamine, but it IS derived from ketamine. It performs with some of ketamine’s traits, but not others.

At Innovative Psychiatry, we embrace treatments that may help. And we hope esketamine will help some who haven’t been helped by traditional antidepressants or anxiety medicines. As you read these articles about esketamine nasal spray, remember this is a new medication and we’ll know more as we use it to treat the conditions it’s been developed to relieve.