Q: I want to prescribe a higher dose than the default weight-based dose. What do I do?
A: You can write in your assessment why you’re ordering more, no problem! The weight-based dissociative dose comes up automatically, but you can order whatever you feel is right for the patient. The maximum amount that can be prescribed is 1200mg total per session so you should never exceed that total amount.
Q: Is there a protocol regarding how much to increase dosages by? Do you increase by 50mg or 100mg for example?
A: Any changes in dosing are individually determined so we don’t have a set formula for a specific increased amount. If they’ve really had very limited effect of their weight-based dose, we have the ability to increase substantially relative to what they’re currently taking. This could be more than 100mg and depends on how much they started with. We have a maximum dosing range we will provide so the dosages are safe. Situations, expectations, and how long someone swishes can impact their experience as well so it's important to educate patients and provide tips to optimize absorption.
Q: What is the maximum dose I can prescribe?
A: You can prescribe up to 1200mg total per session. It can be risky having high amounts kept at home but depending on a patient's history and weight, there’s an option to increase up to 1200mg maximum. Instructing the patient to brush the gums and cheeks beforehand can help with absorption. They could also try pre-dosing with magnesium - there is some anecdotal evidence that it increases the perceived efficacy, so they could pre-dose for a week up to 250-500mg of magnesium glycinate (which is less likely to cause the stomach upset). The patient would take it at bedside every night for a week before the KAP session. Swishing with lemon water might also help after or before.
OptioRx can fit up to 500mg in one RDT of Ketamine. So you could prescribe 2 of the 500mg and a 200mg booster.
Q: My patient's weight is above the dosing guidelines chart. Can I prescribe more based on their higher weight?
A: If the person is over the weight of 280lb, you would still prescribe a rounded dissociative dose of 650mg. It’s okay to increase beyond this using your clinical judgment.
The maximum total amount that can be prescribed per session is 1200mg.
Q: When can I adjust doses? A Patient wants a dose adjustment but isn’t ready for follow-up.
A: We do not prescribe additional ketamine in between follow-ups. A 15 min call can be scheduled by the care coordinators if needed to review the details of a client’s dosing: how many/what dosage the patient has left, the timing they’ve been taking the medication (ie, have they tried taking all 3 at T0), to provide tips to increase absorption (should be vigorously swishing for 10-12, up to 14 minutes; can try buccal brushing; can try sipping warm water right before dosing), and to authorize any changes (not sending a new prescription, but utilizing what they have leftover before they follow-up).
- If authorizing them to take more than what is currently allotted (ie, if they have 6x400mg tablets left and 4x100mg tablets left and it sounds like they truly could benefit from a higher dose, you may authorize them to take 2 booster tablets per session in addition to their full dose instead of 1 booster; ie 1000mg instead of 900mg per session. They will run out of the boosters sooner than anticipated so they’d need to schedule a f/u once they need additional medication). This should be documented via an interim note, and the client should follow your instructions and not exceed beyond the new maximum you tell them. We cannot send new ketamine prescriptions during 15 minute consultations.