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Comment by thinkingkong | Hacker News Reader

The suggested price of these treatments is absurd. “And then there is the cost. It is unclear what insurance companies will cover and treatment estimates are in the vicinity of $7,000 per month.”

Its been awhile but Im fairly confident this drug doesnt cost anywhere near that price.

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Even worse is are the conditions for being prescribed. First you have to have failed 5 previous medications but still be taking one. The dosages are delivered only to your psychiatrist. You have to have it injected there and then you have to wait 2 hours and are not permitted to drive for 24 hours. And that's for the several injections per week...

So not only will the drug be expensive but you're going to be charged a doctors visit every time AND you'll have to figure out how to get off from work for hours each week.

Seems a lot easier to go down to the local high school and buy a bag of K.

My girlfriend did ketamine treatments and her's were once a week for four weeks with a break period in between(don't remember the exact length of the break), where are you seeing the several injections per week number?

Spravato is 2x a week for nasal administration for the first 4 weeks, then weekly or less thereafter. http://www.janssenlabels.com/package-insert/product-monograp... page 2 upper right. Still it's constraining.

Thats not the case for people I know . I know a place that don't need a history of failed AD treatments and each session costs 400$ . After 5 sessions u get a one month supply of oral or intranasal ket for daily use 20mg .

Johnson & Johnson patented and got Esketamine FDA-approved specifically for the treatment of depression, which is literally just the active part of Ketamine, which is otherwise a very cheap generic drug but not approved for the treatment of depression. And with the patent raised prices at least 300x over what Ketamine costs.

And we wonder why drug prices are so high.

Esketamine is just an enantiomer. Both enantiomers are similarly active, and to me it's not 100% clear to me why Esketamine was the enantiomer chosen.

There is no rhyme or reason other than the fact that one or the other could be patented by a private co unlike Ketamine. I assume trying to patent both would've doubled their costs, so why bother, especially if it's highly probable both do the same thing.

Esketamine doesn’t have the same activity as racemic or Arketamine (S- hits some of the dopamine receptors harder and doesn’t bind with the sigma ones iirc). Patients seem to find esketamine more pleasant because of this and it’s eliminated faster than R- so patients can (probably) get back to normal faster.

(Edit: had my right from left mixed up. It’s been a while)

So maybe it makes you a little less groggy but at 300x the price? Don't think anyone can say that justifies the price multiple.

Now r-ket can be developed as a patentable improvement over the state of the art :)

Some studies suggested that the enantiomer they chose was slightly better at driving the effect people thought was causing the anti-depressive effect.

Unfortunately, newer studies suggest that 1) that effect isn't responsible for the anti-depressive effect and 2) the enantiomer they chose doesn't seem to be as good as normal ketamine.

Too soon to say, but early signs suggest this may have all been a fantastically expensive mistake. :(

They started the trials before the NIH study that proved that nmda receptor only played a small role it it's effects and that R-ket and it's metabolite was more important .

They were already too deep it

Take an already active drug, repackage it, patent it, and market it, and nobody knows how much you're charging because thats the insurance companies problem

They ran a bunch of clinical trials on it.

Maybe the gov't should fund trials for the use of generic ketamine to treat depression, and then come to the conclusion that generic ketamine can be used to treat depression (as they've concluded with esketamine) and then any medical profession could prescribe ketamine (in a controlled setting) at 1/300th the price.

The drug was already discovered and in use on humans. Universities everywhere could’ve run clinical trials on it. There’s not much here that’s novel or new, but they get to charge a good used car a month because they ran some trials? Sorry.

No studies on long term use for people with depression . Trials are expensive . esketamine by j&j was done for people that don't have money for clinic which are out of pocket but money enough for insurance

I wonder if just giving some people $7,000 a month would help with depression?

Ooh, this would be a really interesting 'placebo' control. Literally hand the patient the cost of providing the treatment as an alternative condition.

I like the active placebo in cash idea.

Funny, a physician friend once commented that the effectiveness of a placebo seems to be directly proportional to its cost :-)

Until I see a detailed cost breakdown, I am going to assume this is just more of the same graft that has infected the rest of the US healthcare system.

Someone I used to know was a ketamine user for a while -- when she wasn't busy with cocaine. (The impact was pretty drastic, so I'm guessing she was using rather more than might be recommended...) What I came to say, though, was that I'm quite sure she wasn't paying anything like that much for it.

In my experience a gram of K in the US costs around $100

In the UK it is more like $20-$40

This is a bit like comparing street amphetamine powder with prescription adderall. People are willing to pay for a pure product measured precisely in laboratory, not cut with other dangerous chemicals delivered as a pill.

I’m not an expert but I’ve heard that K is so easy to make and cheap, it’s rarely cut.

From what I remember from the Hamilton's Pharmacopeia episode on Ketamine, this synthesis is actually quite complex and a high-yield synthesis (which is presumably being used currently by manufacturers) is not published in publicly available literature.

However, ketamine is widely used as an anesthetic, so I think the "cheap to make" refers to Ketamine redirected from the pharma market to illicit channels, in which case "making" ketamine is just drying the solution to crystalize the sole ingredient.

Street ketamine is almost always redirected pharmaceuticals. We used to buy cases of bottles unopened back in the 90s

This article says _was_ almost always: https://www.bbc.co.uk/news/resources/idt-bc7d54e7-88f6-4026-...

In the specific case of ketamine, it’s easier and cheaper to acquire, and generally goes through far fewer intermediaries between the pharmacy and the street consumer. So the stuff you find on the street tends to be dramatically more pure than, say, cocaine.

Well, I find this.[0]

> Drug maker Johnson & Johnson has stated that the Average Wholesale Price (AWP) for each treatment of esketamine would range from $590 to $885, depending on dosage and excluding administration and observation costs. This implies a twice-weekly treatment during the first month would cost medical treatment centers offering the drug at least $4,720 to $6,785. Subsequent weekly treatments would cost about half as much.

Purchasers and payers with market power will get discounts and/or rebates, of course. But that's still a damn expensive drug. Also, do note that it's the "cost [to] medical treatment centers". Not what they'd charge patients and third-party payers.

0) https://www.coventrywcs.com/content/dam/pdf_assets/first_scr...

Driving it through FDA trials does though.

We've set up a system where we don't let new drugs hit the market unless someone spends billions on testing. That's...mostly good? I guess? But there's no way ketamine will ever be approved in the US unless someone finds a way to charge $7k a dose for it, because otherwise nobody is going to spend the money for approval.

I mean, nothing is stopping you, RIGHT NOW, from crowdfunding a campaign to get the normal version of ketamine through trials, and once you did, it'd be legal to prescribe the "normal" version, and it'd cost a few dollars a dose. Which would (it seem) be a big net benefit to humanity!

It's just, you know...how would you make that work? The cost structure is not favourable.

Ketamine is also available for use as an anesthetic. (It used to be used for most heart surgeries.) It's like $10 a shot when used as an anesthetic.

Some insightful background: https://slatestarcodex.com/2019/03/11/ketamine-now-by-prescr...

It’s still used. Moreso in animals, but still in humans, but usually with another sedative.

Also used in palliative care when opiates aren’t working or causing too many side effects.

Right, my comment about "was used" was for heart surgery. The story I heard was that the patients were complaining about the psychedelic effects :D

It was really interesting to watch "Combat Medics", a show about med-evac choppers for the US armed forces in afghanistan. One of the first things they do with bad cases is give them a shot of ketamine. So in addition to calling K disparagingly "cat tranquilizer" and "horse tranquilizer", we should call it "marine tranquilizer".

The big advantage of it is that it works and it doesn’t mess with heart rate or breathing.

Safe to give without having to monitor much, nor carry other items because it has few contraindications.

I feel like the street price for a months worth of Ketamine would be way less than $7000...

You could get a couple first class flights and VIP tickets to EDM festivals to go with it :p

But research, development, and marketing cost.

IIRC most of the money spent on the development of a successful drug comes from the phase 3 clinical trial. R&D does make up a lot of a drug company's budget but that's because you do the R&D for the 10 drugs you start with, not just the 1 that makes it to market.

It should be a joke for a generic drug company to take generic S-Ketamine and put it in another insufflation device and show bio equivalency.

You don’t patent indications.

I don't think it's a joke that they could patent their special version of ketamine, I think it's a joke that despite the fact that we've been using ketatmine for generations and despite the fact that it's anti-depressant qualities are well attested to in the literature this brand of s-ketamine is the only one doctors are allowed to use. And there's research[1] showing that most of racemic ketamine's effect is from the r-ketamine, not the s-ketamine.

[1]https://www.sciencedirect.com/science/article/pii/S009130571...

There’s no way they were the first to synthesize the S énantiomor.

Usually doctors can still prescribe the compounded forms as long as they’re not duplicating something commercially available.

You don’t patent them, but you do get exclusivity with the FDA approval.

FDA won’t approve another drug for 3-7 years.

Ketamine is practically free to manufacture.

What you're paying for is the FDA approval process for this condition.

Ketamine infusions for depression are pretty expensive, but not $7000/mo. They seem to run about $400-600 per treatment.

Given that patients require constant treatment to benefit from ketamine I'm not sure that helps a ton.

I couldn’t imagine it being that expensive to have a home care nurse set up a peripheral line, mix up the bag and run the infusion (or IV push it).

The drug in vials is generic.

No different than IV antibiotics at home.

Not much clinical monitoring required when you’re on a stable dose.

We're comparing this to the 20$ for a months worth of antidepressants though. It's 1000x more convenient (and cheaper) to take a single pill a day vs setting up an IV.

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