Compounded Intranasal Racemic Ketamine for Major Depressive Disorder: A Case Report

Ketamine has been safely used as an anesthetic for over 50 years. More recently sub-anesthetic doses have shown benefit for treatment-resistant depression (TRD). The majority of data on ketamine for depression is based on intravenous administration which is resource intensive and logistically challenging. Due to these concerns, novel modes of administration, including intranasal, are being explored. In 2019, the U.S. Food and Drug Administration (FDA) approved a commercially formulated intranasal s-enantiomer ketamine product, esketamine, for TRD. The cost of intranasal esketamine is significant and phase III clinical trials have not consistently demonstrated benefit over placebo. We describe a case of a patient with major depressive disorder (MDD) and acute suicidality who achieved rapid remission following three treatments with intranasal racemic ketamine. The associated drug cost was $42 USD, significantly cheaper than commercially available esketamine, and treatment was administered on an inpatient psychiatry ward with basic hemodynamic monitoring. Intranasal ketamine was not associated with significant adverse drug effects and facilitated a relatively short hospital admission. The case report provides support for the use of intranasal racemic ketamine as adjunctive treatment for MDD. Public Health Significance This case report highlights the use of intranasal racemic ketamine as a safe and effective treatment for major depressive episodes and acute suicidal ideation. This novel route of administration can easily be incorporated into a broad range of clinical settings as compared to intravenous ketamine. Compounded intranasal racemic ketamine is significantly cheaper than the commercially available esketamine product.