Vilazodone

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Please enlighten re: sexual dysfunctiuon vs SSRI's, SNRI's, TCAs, MAOI's, Wellbutrin, Remeron, Trazodone, Nefazodone.and Buspirone.

I think it's a 5ht1a blocker like trazodone and buspar. Putatively, 1a agonism causes anorgasmia, so vilazodone should not have sexual side effects (and should block sexual side effects of other serotonergic drugs).

Originally Posted by billypilgrim37

I think it's a 5ht1a blocker like trazodone and buspar. Putatively, 1a agonism causes anorgasmia, so vilazodone should not have sexual side effects (and should block sexual side effects of other serotonergic drugs).

Just don't expect it to act as an antidepressant...

Originally Posted by billypilgrim37

I think it's a 5ht1a blocker like trazodone and buspar. Putatively, 1a agonism causes anorgasmia, so vilazodone should not have sexual side effects (and should block sexual side effects of other serotonergic drugs).

Well, 5ht1a antagonistc and an SSRI. I just have yet to figure out the advantage to this v. an SSRI and buspirone other than not having to dose multiple times per day and perhaps the placebo effect of paying a lot more. I've never used vilazodone because I've had perfectly acceptable results with the SSRI-buspirone combo.

Originally Posted by freaker

Well, 5ht1a antagonistc and an SSRI. I just have yet to figure out the advantage to this v. an SSRI and buspirone other than not having to dose multiple times per day and perhaps the placebo effect of paying a lot more. I've never used vilazodone because I've had perfectly acceptable results with the SSRI-buspirone combo.

Agree with this word per word.

Originally Posted by freaker

Well, 5ht1a antagonistc and an SSRI. I just have yet to figure out the advantage to this v. an SSRI and buspirone other than not having to dose multiple times per day and perhaps the placebo effect of paying a lot more. I've never used vilazodone because I've had perfectly acceptable results with the SSRI-buspirone combo.

Do you mean with respect to sexual dysfunction, or therapeutic efficacy?

I haven't seen any data showing that vilazodone is somehow better in terms of efficicacy, and I doubt it breaks the unwritten rule of all antidepressants working equally as well (per a population, not for an individual).

It is, however much more expensive vs the other antidepressants.

The price per drugstore.com...
10 mg (30 ea): $135.99
20 mg (30 ea): $135.99
40 mg (30 ea): $135.99

That's a heck of a lot more than the $4 SSRIs. Of course there should be a place for vilazodone, just that given it's price, I'd place it lower on the algorithm vs. the $4 antidepressants, or the $20 alternatives such as Sertraline or Wellbutrin. If something is more expensive, unless there's something actually better about, it, I'm likely not going to give it first, second, third, or even fourth.

I'm totally on board regarding cost and efficacy issues. However, I do think that it is significant if vilazodone has significantly less sexual dysfunction than standard SSRI's.

And that needs to be taken into consideration, just that price needs to be done so too. And on that matter why give Vilazodone before Trazodone? I don't see a reason or need to do so unless the person had problems on Trazodone. Some patients are willing to suffer the side effects to save money, others actually enjoy the side effects (e.g. one patient told me he and his girlfriend were loving his delayed orgasm, another liked the reduced sex drive because wouldn't think of sex every single moment of his life), and there are other alternatives such as Wellbutrin, Effexor, Mirtazapine, and Trazodone that too are lesser or non-existent with the sexual side effects.

Choosing to recommend specific medications needs to be smart, not based on a reflex. I know several doctors that just automatically give the same med to every patient without taking things into consideration such as price, side effect profile, efficacy, quality of life, etc.

Of course the more expensive medication may be better, but in this case it's not because it's more expensive. Citalopram and Escitalopram, out of all the antidepressants available tend to have the least amount of side effects. (I know you likely know that. I'm writing this for the medstudents and residents that don't know this). Ultimately a doctor may choose the more expensive medication for the right reasons, but IMHO it shouldn't be simply because it's more expensive, the idiotic decision-making process of "oh that's my favorite medication" (it doesn't matter if it's your favorite, it matters as to whether or not it works well in the patient, can they afford it, and are they having side-effects), and/or the doc that just gives the same med to everyone regardless of what is going on with the patient.

Originally Posted by firedoor

I'm totally on board regarding cost and efficacy issues. However, I do think that it is significant if vilazodone has significantly less sexual dysfunction than standard SSRI's.

Vilazodone does have less associated sexual dysfunction than the SSRIs. However, again, I question whether it offers a utility over an SSRI + Buspirone, as the addition of buspirone to an SSRI has been shown to reduce sexual dysfunction, as well.

Effect of buspirone on sexual dysfunction in depressed patients treated with selective serotonin reuptake inhibitors.
http://www.ncbi.nlm.nih.gov/pubmed/10350034

Now when vilazodone becomes a generic, perhaps. It does carry the advantage of being a single pill, I'll grant you. That would improve adherence over buspirone, which you really have to dose BID or TID.

Perhaps more data will come out over time, be it in terms of efficacy or side-effect profile. I personally prefer Cymbalta over Effexor (any formulation) because you get more noradrenergic action early in the dosing and less HTN (well, plus I see better results / tolerability with it). In this case, I'll almost always prescribe Cymbalta over Effexor. (I am well-aware that some on this forum will take umbrage with this stance, but that's been my experience. I've seen numerous patients benefit from Cymbalta > 60mg, but when I start tuning up Effexor, no one seems to like it and up goes to the blood pressure....)

I may come to liking vilazodone over time. Right now, if I start someone on an SSRI, and they have results but also sexual dysfunction or have ongoing anxiety, I'm looking at adding buspirone as my next step, not switching to vilazodone.

One issue with Viibryd that is not well known but I think may become HUGE is this issue of all known agonist of 5HT-2B in the nanomolar range causes cardiac valvulopathy in long term use. Bryan Roth's, one of the world leaders in psychiatric drugs development, wrote about this and gave a talk about this issue recently as well
http://circ.ahajournals.org/content/102/23/2836.full


I believe because of this FDA wanted the trials for Viibryd to include follow-up echos, and THUS far has not shown any specific effect, but the trend was (I think) worrisome. I can't find offhand the article, but I think it was either an Archieves or AJP paper, and there was a noticable trending of increased valvulopathy that's neverthless not significant.

The potential decreased sexual side effect, in my opinion, does not offset the potential risk that's not very clear yet in terms of post-marketing adverse event tracking etc I would not be surprised if this drug gets pulled off the market in 10 years. I personally, based on all the information I've gathered, would be very weary of this medication.

Originally Posted by sluox

One issue with Viibryd that is not well known but I think may become HUGE is this issue of all known agonist of 5HT-2B in the nanomolar range causes cardiac valvulopathy in long term use. Bryan Roth's, one of the world leaders in psychiatric drugs development, wrote about this and gave a talk about this issue recently as well
http://circ.ahajournals.org/content/102/23/2836.full

To my knowledge vilazodone has negligible if any affinity for 5-HT2B; can you provide documentation of such?

Ran this by one of our big pharm researchers, who said Bryan Roth (the researcher mentioned him by name, not from me saying it) was just trying to get a lot of notoriety out of this but that there's nothing to it.

I have no clue, my source has never failed me, but who knows. In vitro vs in vivo, who knows. It's still a stupid medicine I won't prescribe until it's off patent, unless I learn otherwise.

This thread is a few months old, but I'd like to revisit it. Is anyone exited about using vilazodone? I have seen several folks struggle with headaches and GI effects.

Originally Posted by gabafan

This thread is a few months old, but I'd like to revisit it. Is anyone exited about using vilazodone? I have seen several folks struggle with headaches and GI effects.

I only prescribed Viibryd once and the patient didn't get the Rx filled because they couldn't afford it.

As I mentioned earlier, I'm weary of the claims of decreased sexual SE. In the study cited in the package insert the rate of sexual dysfunction in the control group was much lower than would be expected in the general population. Thus, they were dealing with a virile population to begin with and hence less likely to get sexual SE than the patients I see in general practice.

Also, I use a patient's desire to avoid sexual SE as a "hook" to sell psychotherapy.

Thanks for your input!

Originally Posted by billypilgrim37

Ran this by one of our big pharm researchers, who said Bryan Roth (the researcher mentioned him by name, not from me saying it) was just trying to get a lot of notoriety out of this but that there's nothing to it.

I have no clue, my source has never failed me, but who knows. In vitro vs in vivo, who knows. It's still a stupid medicine I won't prescribe until it's off patent, unless I learn otherwise.

I like using ssri and buspar bc you can titrate EACH one to effect. Cmon, you DO know about Symbiax right?

And both the SSRI and buspar can be off the $4 list.