Latuda work?

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Zenman1

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I don't prescribe this mainly due to our Soldier population but there is one civilian hospital around here that seems to like the Bipolar Diagnosis and the Soldiers come back on Latuda. I usually stop it later as it doesn't work. Anyone have a different experience with it?

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I remember being excited about Risperidone coming out. My mentor told me that I should always hurry up and use new drugs before they stop working. I didn’t get what he was telling me at the time, but now I do.
 
I remember being excited about Risperidone coming out. My mentor told me that I should always hurry up and use new drugs before they stop working. I didn’t get what he was telling me at the time, but now I do.

I don't get it now. Care to enlighten? I see Risperidone being used quite a lot?
 
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http://ajp.psychiatryonline.org/Article.aspx?ArticleID=1763708
Is that why you ask?

I've seen some people on it for bipolar depression. There was definitely some akathisia, which can be concerning in this population since its hard to tease apart psychomotor agitation from mania. I don't foresee this being used as first-line therapy for bipolar depression any time soon, unless they have received an adequate trial of quetiapine (at least 300mg/day), which has the added benefit of improving sleep. I guess the benefit of lurasidone would be less metabolic side effects without the long titration/SJE concerns of lamotrigine. For mania, maintenance, I have no experience, but the consensus seems to be you're better throwing Skittles at them (red is the only FDA-approved color for this, FYI).
 
I don't get it now. Care to enlighten? I see Risperidone being used quite a lot?
He's referring to the fact that in terms of efficacy, and questionably morbidity/mortality, there hasn't been a significant advances in antipsychotics. Or for that matter, lithium/Depakote.
 
I don't get it now. Care to enlighten? I see Risperidone being used quite a lot?
He was just giving me the perspective that he had seen a lot of new products, all of which start with great enthusiasm and promotion. 9 to 12 months later, they become just another one of those.
 
The newer antipsychotics as far as I can tell aren't showing superiority in a generalist sense to the already existing ones, and they are much more expensive. Of course specific individuals could react better to the new stuff. Given that I don't see superiority and the price, I tend to use them 4th line or further down.

There is, however, emerging data on lurasidone for bipolar depression and I haven't tried it much on patients yet for that problem so I'm trying to keep an open mind with it for that specific problem. Add to that specific area, there isn't much available for bipolar depression. This could thrust that medication into a first or second line in my algorithm for bipolar depression once I get enough patients on it and actually start seeing results.
 
The doctors in my hospital love that drug. Personally I don't really see why. I have one pt that responded well to it and that's it. Everyone that is on it is at max dose and also on another antipsychotic. Another complicating factor is that it is not always on their formulary.
I sometimes given to people with diabetes but that is only if they can't/failed on Abilify and Geodon. So for me it's a niche med and a 3rd choice.
 
The doctors in my hospital love that drug.

Ehh, I'm just going to ask because I bet everyone is thinking this. Is there a very cute 25 year old drug rep endorsing the product to the attendings?
 
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Granted I'm only a resident, but in talking with my attendings general consensus is that the newer anti-psychotics Latuda, Saphris, and Fanapt aren't all that great at treating psychosis. From what I've heard from attendings, my own personal experience, and what I've read, I may prescribe it for the depressed phase of those with bipolar but that's it (probably not for schizophrenics). We'll see if my opinion changes with more data.
 
Any psychiatrist that has half a brain is going to have a strong foundation in evidenced-based science when it comes to psychotropics (or anything in medicine). I get peeved when a psychiatrist says prescribing is an art and they are artist. I almost became an artist, and I have a brother who is an artist, and a sister that is a film-director.

It's not an art. If you prescribe Nexium because you like that it's a purple pill, I will start thinking you don't know WTF you are doing, and unfortunately I have seen doctors practice in this manner. The only time people should be giving stuff out where there's no to little evidence-based data is when everything evidenced base has been tried and ruled out. Then the person should at least go onto the stuff that could work based on theory, and then if that doesn't work, you shoot in the dark (all the while, informing the patient, and getting second opinions). I'd hardly call this art.

CATIE gives a good foundation on the older antipsychotics, and I wish that someone would do a CATIE with the newer meds. I have talked to people working with the NIMH and they told me it'd likely never happen.

When you, however, get the existing data with the newer meds, they only show they could be potentially superior in very specific niche areas. It is in those areas, such as bipolar depression, where I'll consider they could be used on something higher than 4th line, but then you have to factor in the cost, and in the areas I practice now, I don't have samples of it, making it difficult for me to give it out much even if I wanted to do so.
 
Prescribing habits aside, being the only pregnancy category B anti-psychotic is a definite perk, and I've had to use it along those lines several times.

It also needs to be taken with meals, like Geodon, for full bio-availability. I've seen way too many patients on it who aren't taking it with meals or who are being given just crackers with it in a hospital setting.
 
Granted I'm only a resident, but in talking with my attendings general consensus is that the newer anti-psychotics Latuda, Saphris, and Fanapt aren't all that great at treating psychosis. From what I've heard from attendings, my own personal experience, and what I've read, I may prescribe it for the depressed phase of those with bipolar but that's it (probably not for schizophrenics). We'll see if my opinion changes with more data.

People thought that about the older second generation drugs as well. I've had attendings tell me that their attendings thought risperidone didn't work likely because it was new and different. With that in mind, I'd be suspicious of attendings making claims like this without data, but unfortunately there's not as much data as we like. I think cost and lack of clear benefit over the older medications right now (except for those mentioned -- possible metabolic benefits, Class B pregnancy drug) would be the primary reasons to use something like Latuda.
 
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People thought that about the older second generation drugs as well. I've had attendings tell me that their attendings thought risperidone didn't work likely because it was new and different. With that in mind, I'd be suspicious of attendings making claims like this without data, but unfortunately there's not as much data as we like. I think cost and lack of clear benefit over the older medications right now (except for those mentioned -- possible metabolic benefits, Class B pregnancy drug) would be the primary reasons to use something like Latuda.

I've seen Latuda work, but I virtually never use Saphris and Fanapt... They just seem like me-too drugs with little to add to the table. I think we are seeing evidence they don't work as well as existing options. See this meta-analysis in Lancet for starters:
http://www.ncbi.nlm.nih.gov/pubmed/23810019
 
Ehh, I'm just going to ask because I bet everyone is thinking this. Is there a very cute 25 year old drug rep endorsing the product to the attendings?
She's not cute, she's drop dead gorgeous. She comes to the office in her tight office suit, and horn rimmed glasses.....But I don't think that's the reason, since the female attendings seems to love this medications as well. I believe it has more to do with the fact that many of the attending in the practice gives speeches at fancy restaurants about how awesome it is.
 
I don't have a terribly fancy N or anything, but I have had the absolute worst *luck* prescribing latuda in terms of relentless akathisia (one of which was the worst I've ever seen actually), more than half had intolerable n/v no matter what we tried , and one case of approx. 20lbs weight gain in 8 weeks. Notably, with one schizoaffective, bipolar-type patient, the akathisia was a huge pain because pt was always revved up and it was hard to tell what was going on since pt was amped up at baseline off meds. The one and only pt it helped was when pt used it to augment an antidepressant at 20mg. Bleh.
 
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She's not cute, she's drop dead gorgeous. She comes to the office in her tight office suit, and horn rimmed glasses.....But I don't think that's the reason, since the female attendings seems to love this medications as well.
"Not that there's anything wrong with that..."
 
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I don't have a terribly fancy N or anything, but I have had the absolute worst *luck* prescribing latuda in terms of relentless akathisia (one of which was the worst I've ever seen actually), more than half had intolerable n/v no matter what we tried , and one case of approx. 20lbs weight gain in 8 weeks. Notably, with one schizoaffective, bipolar-type patient, the akathisia was a huge pain because pt was always revved up and it was hard to tell what was going on since pt was amped up at baseline off meds. The one and only pt it helped was when pt used it to augment an antidepressant at 20mg. Bleh.

why no anticholinergics like cogentin for akathisia?
 
why no anticholinergics like cogentin for akathisia?
Cogent in is helpful for EPS >>>>> subjective akathisia. You'd be better off with propranolol.

Akathisia is not to be underestimated. There was an older study looking at completed suicides amongst patients on antipsychotics and akathisia was overwhelmingly common a complaint prior to suicide.
 
Missed akathisia has been described as the #1 reason for non-compliance. Anticholinergics don’t help much. Beta blockers work reliably well (watch for asthma), but lowering the dose is the first intervention as this is proven to be one of the most dose dependent problems. I don’t know about everyone else, but I don’t have a lot of patients on doses I feel comfortable reducing so it is usually Beta blocker time. I think patients can lack the vocabulary to describe akathisia. It can be a strange unpleasant sensation but hard to describe. When patients say they don’t like their medication, but are vague as to why, it is often this.
 
I think patients can lack the vocabulary to describe akathisia. It can be a strange unpleasant sensation but hard to describe. When patients say they don’t like their medication, but are vague as to why, it is often this.
Excellent advice...



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So far, I am not particularly impressed by latuda. Where I work, I feel that over 90% I work with (county system) has BMI over 30-35.
Thus, I started trying to shift everyone over to more 'weight neutral med'. I sometimes question how weight neutral this med could be, as I've seen people still gain weight while on it. Of course, this could be confounded by the fact that the people I see have pretty unhealthy eating habits.
But as for efficacy, I'ts mixed. For psychosis, I have maybe two patients I can think off the top of my head who have had reduced AH on it without significant side effects. for the others, it hasn't worked, or there is some level of akathisia.
I've tried using it on one patient for bipolar (to prevent mania, even though this would technically be off-label), and that worked.
I've tried it in 3 people at least for its new FDA-approved indication for bipolar depression, but haven't really seen it made an impact yet.
 
So far, I am not particularly impressed by latuda. Where I work, I feel that over 90% I work with (county system) has BMI over 30-35.
Thus, I started trying to shift everyone over to more 'weight neutral med'.
Out of curiosity, do you typically do this after starting metformin for a while? There's been some good results with metformin reducing weight gain from antipsychotics. I'm working on making a policy of clinicians consciously opting out starting metformin if patient has a weight gain of >x% pre-antipsychotic weight.
 
I don't think I would prescribe a new med too quickly. I mean there is a ton of other meds out there to treat schizophrenia. You don't need to start someone on Latuda which is pricey , unless they respond badly to all other meds. Personally I prefer the 1st generation of anti psychotics to the new ones.
 
I've had pretty good results with it with several of my kids. Granted, I don't use it that much because it's wholly off label in kids, but for kids who have gained a lot of weight on Abilify, I've had good results. One kid in particular experienced a surge in appetite and quickly gained 15-pounds on Abilify, and since shifting him to Latuda has had ongoing improvement in his symptoms while at the same time losing almost all of the weight with a noted decrease in appetite.

I've had another kid who was gaining a ton of weight on Zyprexa but was still psychotic, and mom wanted a switch to a more weight neutral option but didn't like Geodon and the kid hadn't don well on Abilify, and well, Latuda worked for both psychosis and normalized mood.

I really like the idea of this medication, as frankly, I think it's terrible that we're at times inducing hyperlipidemia and obesity in kids. If it truly is weight neutral and efficacious, we're utlimately saving money in the long-run by avoiding diabetes and other medical complications. Looking at the effect size in the adult bipolar depression data, it's a bit smaller than what you see in Seroquel, for instance, but the side-effect profile is world's better.
 
But I don't think that's the reason, since the female attendings seems to love this medications as well.

Psychological studies in advertising show that attractive women elicit more of a response among women too and not just men. That's a reason why they put attractive women on the cover of Cosmopolitan, a magazine where the overwhelming majority of readers are female.

IMHO, there should be no love of a medication for an experienced clinician. When one first practices, I can understand someone giving something out, seeing it work, and then develop feelings of reliability and even attachment for a med. That said, this is a sophomoric approach to medicine. You have to break your comfort zone and read up on a large variety of meds, so that you can be the best doctor you can be. Medicine is not about getting into a comfort zone and then limiting their (edit: your own) ability and knowledge of treatment options. It should be about being up to date and providing the best treatment for the specific patient. Personally, I'd expect residents to break out of the "favorite med" paradigm by at least PGY-III if not sooner.

If the attendings are in a "favorite med" paradigm and they're making money giving drug-rep speeches with the same med, it's transparent what's going on.
 
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I use 6 medications for Bipolar Depression - Lithium, Lamictal, Abilify (all non FDA) and Seroquel, Zyprexa/Prozac, and Latuda (all FDA approved).

For Bipolar I, I generally don't use Lamictal, but I will try everything but Zyprexa before I try Latuda.
For Bipolar II/ Other specified Bipolar, I will try everything but Zyprexa before I try Latuda.

That's a general statement. Most of the time, I use Zyprexa as last med in most not all circumstances of Bipolar Depression in the outpatient setting. Inpatient I use it earlier depending on clinical presentation.

I never use Latuda for psychosis as I think it is a poor antipsychotic. I also don't use iloperidone or asenapine. Both are useless and imo, poor antipsychotics.


That being said, I have used Latuda a decent amount. Currently have it working on 4 patients with Bipolar Depression. All at 40mg. I have had to stop it in 2 patients due to akathesia and 1 patient due to allergic reaction. Patients definitely like it a lot more than Seroquel.

Also remember Latuda has very minimal QT prolongation so I will use it in patients with QTc > 490 that either can't tolerate Abilify or have had a poor response.
 
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Prescribing habits aside, being the only pregnancy category B anti-psychotic is a definite perk, and I've had to use it along those lines several times.

It also needs to be taken with meals, like Geodon, for full bio-availability. I've seen way too many patients on it who aren't taking it with meals or who are being given just crackers with it in a hospital setting.

from what I understand it's Cat B prolly only due to lack of data at this point since it's new....likely to emerge as Cat C like the other drugs in the same class once more info becomes available over time
 
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