Ketamine troches are a compounded prescription medication designed to dissolve slowly in the mouth, usually between the cheek and gum or under the tongue. They are prescribed off-label, under a prescriber's supervision, for treatment-resistant depression and related mood conditions. Ketamine is an NMDA-receptor antagonist that acts on the brain's glutamate signaling differently from SSRIs and other standard antidepressants. Each troche is prepared by a licensed pharmacy at the strength ordered by the patient's provider.
Injectable ketamine is FDA-approved as an anesthetic, while an intranasal form of its S-enantiomer, esketamine (Spravato), is FDA-approved for treatment-resistant depression and administered in a certified healthcare setting. There is no FDA-approved ketamine troche for psychiatric treatment. Compounded ketamine troches are available only by prescription and are used off-label. Ketamine is a Schedule III controlled substance and requires an electronic controlled-substance prescription.
How does it work?
Most antidepressants act on serotonin, norepinephrine, or dopamine and may take several weeks to help. Ketamine works on a different system by blocking the NMDA glutamate receptor. This appears to initiate a series of changes in synaptic signaling and connectivity within the brain (StatPearls, Ketamine).
This difference is why prescribers may consider ketamine when several standard antidepressants have not worked, a situation known as treatment-resistant depression. For some patients, effects may appear over hours to days rather than weeks. A troche dissolves slowly in the mouth so ketamine can be absorbed across the oral mucosa before the remaining medication is swallowed.
What is it used for?
Providers prescribe compounded ketamine troches off-label, most often for treatment-resistant depression and sometimes for related mood conditions, as part of a supervised treatment plan. The strongest evidence for ketamine in depression comes from clinician-administered intravenous ketamine and FDA-approved intranasal esketamine. Evidence supporting compounded buccal, sublingual, and oral ketamine formulations is growing but remains more limited (Swainson et al., Frontiers in Psychiatry 2022).
Only a licensed provider can determine whether this formulation is appropriate for a particular patient. Bayview Pharmacy does not provide psychiatric consultations or determine whether a patient is a candidate for ketamine treatment. A valid prescription is required.
Used within a supervised plan
Compounded ketamine is prescribed as part of a structured treatment plan that may include medical and psychiatric screening, individualized dosing instructions, monitoring, and follow-up. The prescriber determines whether treatment is appropriate, where each dose should be taken, and whether another person or healthcare professional should be present.
Ketamine may be prepared in different customized dosage forms depending on the prescriber's treatment plan. Learn more about our compounded ketamine rapid dissolve tablets and compounded ketamine nasal spray.
How does it compare to other treatments?
Ketamine may be administered in several dosage forms that differ in how they are used, how quickly they dissolve or absorb, their FDA status, and the treatment setting. The table below is provided for education only.
| Option | What it is | Notes |
|---|---|---|
| Compounded ketamine troche | Racemic ketamine prepared in a slowly dissolving buccal or sublingual dosage form | Compounded only; prescribed off-label within a prescriber-supervised treatment plan |
| Compounded ketamine rapid dissolve tablet | Racemic ketamine prepared as a rapidly dissolving sublingual tablet | Compounded only; prescribed off-label according to individualized prescriber instructions |
| Compounded ketamine nasal spray | Racemic ketamine administered intranasally | Compounded only; prescribed off-label within a monitored treatment plan |
| Esketamine (Spravato) | S-enantiomer of ketamine administered intranasally | FDA-approved for treatment-resistant depression and administered in a certified healthcare setting under a REMS program |
| Intravenous ketamine | Racemic ketamine administered intravenously | Clinician-administered in a monitored setting and the most extensively studied racemic ketamine route for depression |
These options are described for education only and are not a statement that any one formulation is better, stronger, safer, or more effective. The patient's provider selects the medication, dosage form, route, dose, treatment setting, and monitoring plan.
How is it used?
Ketamine troches should be used according to the exact strength, portion of a troche, schedule, and treatment setting established by the prescriber. Depending on the prescription directions, the troche may be placed between the cheek and gum or under the tongue and allowed to dissolve slowly. Do not chew or swallow the troche whole unless specifically directed by the prescriber.
Patients should remain seated while the dose takes effect and follow their prescriber's instructions regarding supervision, observation, and monitoring. Do not drive, operate machinery, or perform activities requiring full alertness until the effects have completely worn off. Never increase the dose, use the medication more frequently than prescribed, or discontinue treatment without speaking with the prescriber.
Side effects & safety
Common short-term effects include dissociation, which may feel like detachment from the body or surroundings, dizziness, drowsiness, nausea, altered perception, increased saliva, changes in taste, and a temporary increase in blood pressure. Long-term or heavy ketamine use has been associated with bladder and urinary symptoms (StatPearls, Ketamine).
Patients should tell their provider about heart or blood-pressure conditions, substance-use history, psychiatric conditions, bladder problems, and all prescription medications, over-the-counter medications, and supplements they use.
Seek emergency care for chest pain, trouble breathing, severe confusion, loss of consciousness, or symptoms of a serious allergic reaction. Anyone experiencing a mental health crisis or thoughts of self-harm should call or text 988 for the Suicide & Crisis Lifeline or seek emergency care.
Who should not use it?
Ketamine troches are not appropriate for everyone. They should not be used by patients with a known allergy to ketamine or any ingredient in the compounded preparation. Ketamine may require additional caution or may not be appropriate for patients with uncontrolled high blood pressure, certain heart or blood-vessel conditions, a history of substance misuse, certain psychiatric conditions, or bladder problems.
Patients should tell their provider if they are pregnant, planning to become pregnant, or breastfeeding. The prescriber should review the patient's complete medical history and medication list before determining whether compounded ketamine is appropriate.
How should it be stored?
Ketamine is a Schedule III controlled substance. Store the troches according to the instructions on the prescription label in a secure location that is out of reach of children, teenagers, visitors, and anyone for whom the medication was not prescribed.
Keep the troches in their original packaging and protect them from excessive heat or moisture unless the prescription label provides different instructions. Never share ketamine with another person. Take only the prescribed amount, keep track of the medication supply, and follow the pharmacist's instructions for disposing of unused or expired medication.
Why is this compounded?
There is no FDA-approved ketamine troche for psychiatric treatment. Compounding allows a licensed pharmacy to prepare ketamine in a customized, slowly dissolving dosage form at the strength ordered by an authorized prescriber.
As a 503A compounding pharmacy, Bayview Pharmacy prepares each prescription for an individually identified patient using quality ingredients and applicable compounding standards. Compounded preparations are not reviewed or approved by the FDA.
Explore ketamine dosage forms
Learn more about other compounded ketamine formulations available from Bayview Pharmacy:
Clinical details for prescribers
Regulatory status. Ketamine is a Schedule III controlled substance. Racemic ketamine is FDA-approved as an anesthetic. Intranasal esketamine (Spravato) is FDA-approved for treatment-resistant depression under a REMS program. No compounded ketamine product is FDA-approved for a psychiatric indication, and the FDA has issued safety communications concerning compounded ketamine, including at-home use without appropriate monitoring.
Formulation. Compounded ketamine HCl troches are prepared in individualized strengths specified by the prescriber. Troches are designed to dissolve slowly in the buccal or sublingual space. The prescribed strength, portion of a troche, frequency, quantity, treatment setting, and monitoring requirements are prescriber-directed.
Information about additional compounded dosage forms is available on the ketamine rapid dissolve tablet and ketamine nasal spray formulation pages.
Evidence base. Relevant literature includes intranasal esketamine (P&T 2019), racemic ketamine randomized controlled data (KADS, British Journal of Psychiatry 2023), and reports involving off-label sublingual or at-home ketamine use (Frontiers in Psychiatry 2022).
EPCS and prescribing points:
- Schedule II through V prescriptions must be signed and transmitted electronically when required by applicable state law.
- Select Ketamine bulk powder as the controlled medication so the EPCS signature validates. Do not select the brand name Ketalar.
- Include the prescribed troche strength, complete administration directions, diagnosis code when required, quantity, and authorized refills.
- Specify whether the patient should use a whole troche or a scored portion and whether administration should be buccal or sublingual.
- Counsel patients regarding dissociation, sedation, driving restrictions, secure storage, misuse risk, and the prescribed setting and monitoring requirements.
Bayview Pharmacy may dispense controlled-substance prescriptions to patients in RI, MA, CT, NJ, NH, and FL, subject to applicable prescription and dispensing requirements. Background references include StatPearls, Ketamine and the FDA Compounding Risk Alerts.
This is a prescription compounded medication and is not FDA-approved. This information is educational and is not medical advice. The patient's provider determines whether ketamine is appropriate and establishes the formulation, dose, treatment setting, monitoring, and follow-up plan.
