Ketamine Troches vs. Nasal Spray: Compounded and Brand-Name Options

Nasal Spray, Injectable, and Troche: Comparing Cost and Access

Patients comparing ketamine nasal spray vs injectable cost will find a wide spread depending on the product and the setting. Compounded ketamine nasal spray generally costs $200 to $500 a month for home use. FDA-approved esketamine nasal spray (Spravato) costs $590 to $900 per device before insurance and must be given in a certified clinic. Injectable ketamine, delivered as an intravenous (IV) or intramuscular (IM) infusion, typically costs $400 to $800 per clinic session, with a full six-session induction course often totaling $2,400 to $4,800. Sublingual ketamine troches, the fourth home-based option, run about $250 to $700 a month. This article compares all four routes on molecule, bioavailability, monitoring requirements, and price so you can weigh cost against access and clinical evidence.

The Molecular Distinction: Ketamine vs. Esketamine

Racemic ketamine, used in troches, compounded nasal spray, and IV/IM infusions, is a 50/50 mixture of two mirror-image molecules called R-ketamine and S-ketamine. Both enantiomers are pharmacologically active and bind NMDA receptors differently; see the PubChem ketamine compound summary for full chemical and pharmacokinetic data. R-ketamine may contribute antidepressant effects through mechanisms beyond NMDA receptor antagonism alone.

Esketamine, the active ingredient in Spravato, contains only the S-enantiomer. S-ketamine is roughly twice as potent at NMDA receptors as R-ketamine, so lower absolute doses produce comparable NMDA blockade. Esketamine was developed and approved as its own pharmaceutical product, separate from generic racemic ketamine, with its own clinical trial program. Some researchers argue that combining both enantiomers, as racemic ketamine does, produces effects that S-ketamine alone does not fully replicate, though this remains an open scientific question. See our overview of sublingual ketamine research for more on how the enantiomers compare.

Compounded Ketamine Nasal Spray

Compounded ketamine nasal spray is a solution of racemic ketamine HCl in a buffered saline or other vehicle, prepared by a licensed compounding pharmacy and delivered through a nasal atomizer. Like troches, it is prescribed by a licensed provider and compounded under 503A or 503B pharmacy regulations.

Nasal mucosa is one of the most permeable and vascular tissues accessible without an injection, so intranasal bioavailability of compounded ketamine sprays runs about 25 to 50 percent, somewhat higher than the 20 to 30 percent typical of sublingual troches, with a faster onset of 5 to 15 minutes. Effects generally last 30 to 60 minutes, shorter than a troche session. Absorption is sensitive to technique and health: nasal congestion from a cold or allergies can cut absorption by 30 to 50 percent, and repeated use can irritate the mucosa.

Compounded nasal spray is patient-administered at home with no clinic visit required, and costs about $200 to $500 a month, similar to troches. See our comparison of troche onset, peak, and duration timelines for how this stacks up against sublingual dosing.

FDA-Approved Esketamine (Spravato)

Spravato is the brand name for esketamine nasal spray, manufactured by Janssen Pharmaceuticals and approved by the FDA for treatment-resistant depression (TRD) in adults and for major depressive disorder with acute suicidal ideation or behavior (MDD-SI), used alongside an oral antidepressant. Unlike compounded troches or nasal spray, Spravato went through Phase 2 and Phase 3 clinical trials before approval; you can review its approval record in the FDA's Drugs@FDA database.

Spravato delivers esketamine intranasally with roughly 48 percent bioavailability through a calibrated device that gives two sprays per unit, 28 mg per spray, for 56 mg total. Because of its REMS (Risk Evaluation and Mitigation Strategy) program, every dose must be given in a certified outpatient clinic, with monitoring for at least two hours afterward and no driving allowed that day, a schedule that makes Spravato logistically closer to an IV infusion than to a self-administered nasal spray.

Dosing starts at 56 mg or 84 mg twice weekly for four weeks (acute phase), then tapers to weekly dosing for four weeks and eventually weekly or biweekly maintenance. Spravato's FDA approval makes it more likely than compounded options to receive insurance coverage; some commercial insurers and Medicare cover it for qualifying diagnoses, though prior authorization is common and not every patient qualifies. Our guide to ketamine insurance coverage gaps and patient assistance covers what to ask your insurer before starting treatment.

At list price, Spravato runs $590 to $900 per device, and the 84 mg dose may require two devices per session, so an unsubsidized acute course can run into the thousands of dollars. With insurance, out-of-pocket costs vary from minimal, with manufacturer copay assistance, to several thousand dollars a month.

How Does Injectable (IV/IM) Ketamine Cost Compare?

Injectable ketamine, given as an IV infusion or IM injection in a clinic, is not FDA-approved for depression; it is used off-label, drawing on the same racemic ketamine compound found in troches and compounded nasal spray. IV ketamine goes directly into the bloodstream, so its bioavailability is effectively 100 percent, while IM injection is typically around 93 percent, both considerably higher than sublingual or intranasal routes. Sessions usually last 45 minutes to an hour, longer than a nasal spray session but comparable to or shorter than a troche session.

Cost varies by clinic and region, but IV/IM ketamine sessions commonly run $400 to $800 each, and a standard six-session induction series often totals $2,400 to $4,800 before any maintenance dosing. That is generally more per session than a troche or compounded nasal spray dose, but individual sessions can cost less than a Spravato device, depending on dose and clinic. Because it is off-label, IV/IM ketamine is rarely covered by insurance the way Spravato can be, and patients typically pay out of pocket. It also requires clinic visits, IV placement or injection, and a recovery period before driving, similar in logistics to Spravato but without the REMS documentation requirement. For more on how troches stack up against clinic infusions on price and outcomes, see our troches vs. infusion outcomes comparison and our dedicated look at troche vs. IM ketamine.

Clinical Efficacy Considerations

Spravato has the strongest regulatory evidence of any option here: the FDA approved it based on randomized controlled trials. Even so, multiple systematic reviews and meta-analyses have found that racemic IV ketamine performs at least as well as, and in some analyses better than, esketamine on antidepressant outcomes, a pattern some researchers attribute to the added contribution of R-ketamine. According to StatPearls, a peer-reviewed clinical reference on ketamine pharmacology, both enantiomers act on NMDA and non-NMDA pathways relevant to mood regulation.

The evidence base for compounded sublingual troches specifically is smaller than for Spravato or IV ketamine, since troches have not been through the same scale of controlled trials. Clinical experience across outpatient ketamine practices suggests troches can produce effects comparable to lower-dose IV or IM protocols when doses are properly calibrated, but this is observational experience, not trial-level evidence. Choosing Spravato mainly because it carries FDA approval, while discounting the monitoring burden and cost, will not necessarily produce a better outcome for every individual compared with a well-managed troche or infusion program.

Which Option Is Right for You?

Choose Spravato if:

• You have TRD or MDD-SI and your insurer covers Spravato
• You value the FDA-approved evidence base and professional monitoring during sessions
• You have access to a Spravato-certified clinic and reliable transportation
• You are not a candidate for home-based therapy

Choose IV/IM injectable ketamine if:

• You want the fastest onset and highest bioavailability of the options here
• You are comfortable with clinic visits and can arrange a ride home
• Your provider recommends infusion-level dosing based on your history

Choose compounded nasal spray if:

• You want faster onset than troches but prefer home administration
• You do not have significant nasal congestion or mucosal issues
• Your provider prefers this formulation for your specific situation

Choose troches if:

• You want the longest session duration for extended therapeutic processing
• Swallowing or nasal issues make other routes impractical
• Cost and home flexibility are primary concerns

For a closer look at what troches cost in practice, see our breakdown of ketamine troche pricing.