Ketamine troches vs Spravato vs IV infusions
All three deliver ketamine or its close relative esketamine. They differ a lot in evidence, cost, where you take them and how much monitoring is involved. Here's the honest comparison we give patients.
| At-home ketamine troches | Spravato (esketamine) nasal spray | IV ketamine infusions | |
|---|---|---|---|
| What it is | Compounded racemic ketamine lozenge dissolved under the tongue | FDA-approved esketamine (one half of the ketamine molecule) as a nasal spray | Racemic ketamine given through an IV line over about 40 minutes |
| FDA status for depression | Off-label; compounded product | Approved for treatment-resistant depression and for depression with suicidal thoughts | Off-label |
| Where you take it | At home, with a trusted adult present | Only in a certified clinic, with 2 hours of observation each dose | In a clinic or infusion center |
| Typical schedule | Usually 1–3 sessions per week at first, then tapered | Twice weekly for 4 weeks, then weekly or every other week | Often 6 infusions over 2–3 weeks, then boosters |
| Insurance | Appointments billable; medication usually not covered | Often covered, with prior authorization; clinic visit costs apply | Rarely covered |
| Typical cost | Medication under $80/month plus visits | Varies widely with coverage; list price is high without it | Commonly several hundred dollars per infusion, self-pay |
| Strength of evidence | Growing, but fewer controlled trials than IV; absorption under the tongue is lower and more variable | Multiple large controlled trials; the best-studied non-IV option | The most studied route; fastest and most reliable delivery |
| Best suited for | People who need a low-cost, flexible option and can follow a safety protocol at home | People whose insurance covers it and who can get to a certified clinic twice a week initially | People with severe or urgent symptoms who can afford self-pay infusions |
Why we usually start with troches
For many Michigan patients, the deciding factors are access and cost. Spravato requires a certified treatment center and two hours of supervised time per dose, twice a week to start, which is hard to combine with work or caregiving. IV infusions are the gold standard for evidence but are rarely covered and can cost thousands over a course.
At-home troches sit in the middle: lower cost, more convenience, and a reasonable evidence base, with the trade-off that dosing is less precise and the research is younger. We think that trade-off is worth it for the right patient, and we say so only after a full evaluation.
When we'd point you elsewhere
- Severe depression with active suicidal thinking. Spravato is specifically approved for this, in a monitored setting, and we would refer you.
- Your insurance covers Spravato and a certified clinic is nearby. That may be the better-evidenced, lower-cost path for you.
- Troches haven't helped after a fair trial. Some people respond to IV ketamine when sublingual dosing doesn't reach an effective level.
We don't offer Spravato or IV infusions ourselves, so we have no financial reason to steer you one way or another.
Want to talk through which route fits your situation? Call (734) 999-3505 or Book a new-patient evaluation.