What is practical experience with newest atypicals?

[Igor4sugry]

What sort of experience do you find with using Saphris, Latuda, Fanapt (this one didn't catch on it seems) maybe even Vryalar for psychosis and mania? In my training institution these are simply not routine and we stick to the more established atypicals (risp, invega, zyprexa, etc). I have some experience with Latuda, and Saphris limited to outpatient. But none with Vryalar.
Is medicaid covering these medicines now? What about private insurance?
Saphris seems attractive for inpatient due to quick dissolvable formulation, and maybe negative symptoms?
Anyone trying Pimavanserin off-label?

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[PistolPete]

I've only ever used Latuda of the ones you mention (kudos to the VA for having it on their formulary!). So far I''ve gotten decent results with it, but we shall see long term. I think only private insurance will cover most of those atypical, and Medicaid only with extensive prior authorization documenting prior failure.

I'm curious to see the long-term effects of Nuplazid in Parkinson's patients.

 

[splik]

medicaid is a state program so it depends on the state. where i went to residency the state medicaid bizarrely paid for the new ones without prior auth (but wouldn't cover things like naltrexone without PA which i thought was ridiculous). I was not particularly impressed with saphris but quite a few patients seemed to like it. Had a fairly benign adverse effect profile, but it didn't seem to have too much therapeutic effect either. It is not good for inpatient - it is not orodispersible - instead it has a bizarre system where you have to keep it under your tongue for quite a while, then it dissolves, and then you have to swallow it (it's still absorbed through the gut, not sublingually), and many pts cant use it correctly.

I found no advantage of using fanapt over other atypicals like risperidone. It does not confer any advantage, has a similar profile to risperidone (structually v similar) but a greater risk of QTc prolongation (similar to ziprasidone).

Latuda I commonly used for bipolar disorder with mixed results. I will use it quite a bit for bipolar depression. I also used in some patients with borderline personality disorder w/ severe dissociative symptoms. It is quite well tolerated and does not appear to cause weight gain for the most part so I am quite keen on it

 

[HarryMTieboutMD]

In my experience Latuda is a mediocre antipsychotic but works really nicely as an antidepressant (as Splik mentioned). I have yet to use it in MDD with mixed features (there was a recent AJP paper on this). Because Vraylar was just approved for mania I think you can do a prior auth through medicaid if nothing else is really an option... no idea how well it works, but somehow I doubt D3 blockade will add that much more...

 

[F0nzie]

Latuda meh, Saphris- I don't think any of my patients have liked it, Vraylar- pending reports from patients, Rexulti - thumbs up so far, 2 for 2.


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[wolfvgang22]

I've had good results with Latuda and Saphris, both are well tolerated, but I don't rely on them when I need a medication for an extremely manic patient. They seem to work better as something to transition to once someone has been stabilized on Risperidone/Quetiapine/Aripiprazole and a mood stabilizer.

 

[Crayola227]

a psychiatrist indicated to me that aripiprazole is very similar to Latuda in having more activating effect than say, seroquel, and so if a patient didn't tolerate aripiprazole they didn't see a point to trying Latuda

thoughts?

 

[whopper]

Abilify-well it's not so new anymore but I've been prescribing aripiprazole since the generic is now out and it's no more expensive than the other generics for atypicals. I previously made it 3rd line for weak psychosis due to the price.

All the other new ones I avoid unless there's specific reason to give it and it's due to the price. I've been giving out Latuda first line at times for bipolar depression cause the data now supports it first-line and have seen success with it but for as many successes I see too many patients wanting off due to EPS. Many of the times I prescribed it the insurance company wouldn't pay for it and it's hundreds of dollars a month otherwise.

Fanapt-only gave it out if a pharmacogenomic test recommended it with no other meds recommended or they were already tried and failed. Again in general I don't make it first, second or even third line due to price. In those cases it did work well.

In general I don't see significant reason to give the newer atypicals first line over the older ones except for Latuda cause again the data does support it for first-line use in bipolar depression but that's it.

 

[deleted736562]

nonsense they aren't similar at all. abilify is a dopamine parish agonist rather than antagonist and has s very high affinity for the D2 receptor. it is also very activating and commonly causes akathisia. it also has a very long half life which is what makes it so useless in the acute setting. latuda is not typically sedating but it is not exactly activating. abilify is not indicated in the treatment of bipolar depression whereas abilify may well be. latuda is commonly used after abilify has failed and can sometimes be helpful

What do you think about a Haldol/Abilify combination? I've read some case reports that partial dopamine agonism of Abilify may dampen some of the EPS associated with Haldol. Not sure if this has any effect on efficacy.