Compounded Ketamine Formulations: Lozenges, Troches, and Creams

Compounded ketamine formulations are custom-prepared versions of ketamine made by licensed compounding pharmacies to a prescriber's exact specifications, including sublingual troches and lozenges, rapid dissolve tablets, nasal sprays, topical creams, and oral solutions. Unlike the two commercially manufactured ketamine products sold in the United States, generic injectable ketamine approved for anesthesia and Spravato (esketamine) nasal spray approved for treatment-resistant depression, compounded formulations let prescribers offer oral, sublingual, or topical delivery routes that no drug manufacturer currently produces. The growth of at-home psychiatric ketamine treatment has made compounded ketamine one of the most frequently prepared psychiatric compounds in the United States. This guide explains how each formulation works, typical dosing and bioavailability, and the regulatory and quality factors patients should understand before starting treatment.

What Are Compounded Ketamine Formulations?

Compounded ketamine formulations are individually prepared by a compounding pharmacy to meet a need a mass-produced drug can't, such as a specific dose, a flavored troche instead of a swallowed pill, or a topical cream instead of an injection. The FDA notes that compounded drugs are not FDA-approved, meaning they have not been evaluated by the agency for safety, effectiveness, or quality before reaching patients. That gap places more responsibility on prescribers and pharmacies to follow recognized compounding standards. Demand for compounded ketamine has grown alongside interest in at-home psychiatric treatment, since the only commercially available ketamine products remain generic injectable ketamine for anesthesia and Spravato (esketamine) nasal spray for treatment-resistant depression.

Types of Compounded Ketamine Formulations

Sublingual Troches and Lozenges

Sublingual troches, sometimes spelled "trochees," and lozenges are the most commonly prescribed compounded ketamine formulations for psychiatric use. These solid dosage forms are held under the tongue or between the cheek and gum so ketamine absorbs through the oral mucosa directly into the bloodstream. Doses typically range from 50 to 300 mg per troche, though prescribers sometimes go higher. Bioavailability runs approximately 25 to 35% sublingually, varying with how long the troche stays under the tongue, whether saliva is swallowed or spit out, and individual mucosal absorption. Effects usually begin within 10 to 20 minutes and last 45 to 90 minutes. Because ketamine tastes bitter, compounding pharmacies typically add flavoring agents to improve tolerability.

Patients are usually instructed to hold the troche under the tongue for 10 to 15 minutes to maximize absorption, then swallow or spit out the remaining saliva. Whatever portion is swallowed passes through first-pass liver metabolism, which lowers its effective bioavailability.

Rapid Dissolve Tablets (RDTs)

Rapid dissolve tablets are a newer compounded formulation for sublingual use. They dissolve faster than traditional troches, which may improve mucosal contact and patient experience. RDTs may reach slightly higher bioavailability than standard troches because of faster dissolution, though comparative pharmacokinetic data remain limited.

Nasal Sprays

Compounded intranasal ketamine sprays deliver ketamine through the nasal mucosa, avoiding first-pass liver metabolism. This route offers higher bioavailability, approximately 25 to 50%, and a faster onset, 5 to 15 minutes, than oral administration. Compounded nasal sprays differ from Spravato in several ways: they typically contain racemic ketamine rather than esketamine alone, they are not FDA-approved for any indication, and they are not subject to the REMS (Risk Evaluation and Mitigation Strategy) program that governs Spravato. Dosing and concentration vary by prescription and pharmacy, and compounded nasal sprays are generally less expensive than Spravato.

Topical Creams and Gels

Topical ketamine formulations, including creams, gels, and ointments, are prescribed mainly for pain management rather than psychiatric conditions. They are applied directly over painful areas to reach peripheral nerves and local tissue. Common applications include neuropathic pain conditions such as complex regional pain syndrome, diabetic neuropathy, and post-herpetic neuralgia, along with musculoskeletal pain, post-surgical pain, and chronic wound pain. Concentrations typically range from 2% to 10% and are sometimes combined with other analgesics such as gabapentin, baclofen, diclofenac, or lidocaine. Systemic absorption from topical application is minimal, so these formulations generally do not produce psychoactive or dissociative effects.

Oral Solutions and Suspensions

Some compounding pharmacies prepare ketamine as a liquid oral solution or suspension. According to a pharmacokinetic review published in CNS Neuroscience & Therapeuticsoral ketamine bioavailability ranges from roughly 17% to 24%, the lowest of the commonly used administration routes, because it undergoes extensive first-pass liver metabolism. Its primary metabolite, norketamine, has pharmacological activity of its own and may contribute to the therapeutic effect. Oral formulations are sometimes used for chronic pain management or as a longer-acting, lower-intensity maintenance option for patients who have already responded to initial IV or IM ketamine treatment.

These figures are approximate and vary by individual. Mucosal integrity, gastrointestinal motility, liver function, body composition, and other medications all affect absorption. For a fuller breakdown of how absorption and dosing relate across routes, see our guide to ketamine bioavailability.

Clinical Uses of Compounded Formulations

At-Home Psychiatric Treatment

The most common current use of compounded ketamine is at-home psychiatric treatment. Prescribers, often psychiatrists or other mental health providers working through telehealth platforms or in-person clinics, prescribe sublingual troches or lozenges for patients to take at home under clinical guidance on dosing, frequency, and safety. Typical at-home protocols include an initial evaluation to establish diagnosis and candidacy, prescription of a specific formulation and dose, instructions for a treatment sitter (a sober, responsible adult present during sessions), remote monitoring through follow-up appointments, and clear guidance on when to contact the prescriber or seek emergency care. For more on structuring a safe session, see our guide to set and setting.

Chronic Pain Management

Compounded ketamine in topical, oral, and sublingual forms is used for chronic pain, particularly conditions that have not responded to conventional analgesics. Ketamine's multi-modal analgesic properties, including NMDA receptor blockade, anti-inflammatory effects, and opioid-sparing activity, make it a versatile addition to pain management regimens.

Transitional and Maintenance Therapy

For patients who have responded to initial IV or IM ketamine treatment, compounded sublingual or intranasal formulations can serve as maintenance therapy, allowing continued treatment outside an infusion clinic. This approach can reduce cost and improve convenience, though it trades off lower bioavailability and less direct clinical oversight. See our overview of ketamine treatment methods for how these approaches fit together.

Quality and Regulatory Considerations

Compounding Pharmacy Standards

Compounding pharmacies in the United States are regulated at both the state and federal level. State boards of pharmacy set their own rules on facility standards, documentation, and practitioner oversight. The United States Pharmacopeia (USP), a nonprofit organization that sets quality standards for medications, publishes compounding standards including USP <795> for non-sterile compounding and USP <797> for sterile compounding. Under the Drug Quality and Security Act of 2013, compounding pharmacies that prepare large quantities of medication without individual prescriptions, known as outsourcing facilities or 503B pharmacies, must register with and be subject to inspection by the FDA.

Quality Variability

A significant concern with compounded medications is quality variability. Clinical references, including StatPearls' review of ketamine pharmacology, note that some compounded medications deviate from their labeled potency, meaning patients may receive more or less ketamine than prescribed. Choosing a pharmacy that follows current USP standards and undergoes regular third-party potency testing is an important safeguard for both prescribers and patients.