Abilify 5mg--the new money waster?

[whopper]

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I've noticed a new trend. It seems a significant portion of the community doctors are now giving out Abilify 5mg like its candy.

Why? Well the only justification I can think of is the ad blitz for the antidepression augmentation. However I've seen some psychiatrists give it where no depression augmentation was needed.

Some examples....
Hmm--pt has PTSD The treating psychiatrist put the pt on on Zoloft 100mg and Abilify 5mg. Why augment the Zoloft when the maximum dose was not yet reached and the patient has no side effects? No, there is no MDD with or without psychotic features. The person has an anxiety disorder. Its a anti-depression augmentation agent, not an anti-anxiety augmentation agent as far as I'm aware.

Borderline patient is given Abilify 5mg even though they're not put on anything else. Hmm--what a great augmentation agent, Abilify 5mg and there's nothing there for it to augment.

What about the other augmentation agents that were put through STAR*D? Buspirone is only $4 a month, it has plenty of data to support it as an antidepression and antianxiety augmentation agent, and it won't require a psychiatrist to now expensive draw labs on the patient that are the standard for antipsychotics.

Yes I can justifiably see someone being put on Abilify 5 mg if they truly needed the antidepression augmentation, and the antidepressant has reached the maximum dose, but why not use one of the cheaper and safer meds? Anything show Abilify as superior to Buspirone?

I can justifiably see someone putting someone on Abilify 5mg if that person had MDD with psychotic features because a low dose antipsychotic in that case is justified, though I've yet to see any other doctor do it for that reason out of the several Abilify 5mg cases I've seen. (And in that case, you really can just put them on a low dose of Risperdal which is becoming ever cheaper).
Anyone else seeing this trend?

 

[Psychelle]

I'm seeing ads for Abilify everywhere. Perhaps some of this reflects patients "asking their doctors". Though I think if they put on those ads "this is an antipsychotic" a lot fewer would ask.

 

[Regnvejr]

I use it, but with care, as it has side effects in quite a bit of the patients I try it on, mainly akasthisia, nausea, and weight changes.

And in children, especially, it often gives paradoxical aggitation (and to some extend in adolescents), making it somewhat of a risky gamble. Better watch them closely.

 

[facetguy]

I'm seeing ads for Abilify everywhere. Perhaps some of this reflects patients "asking their doctors". Though I think if they put on those ads "this is an antipsychotic" a lot fewer would ask.

Physicians are never influenced by ads or other pharma marketing efforts😱!

 

[Psychelle]

No, no, of course not. 😉

 

[Anasazi23]

I don't think Abilify in low dose is the worst choice for what I call 'outpatient psychosis' or their derivatives. We all know that many of our patients have pathology sets that straddle the fence between disorders.

The PTSD patient you describe would most likely, as you corrently state, need maximization of the zoloft. However, we don't know if that same patient had an untoward side effect which required a dose lowering (sexual side effect, etc), and that the abilify if being tried as an augmenter. I've also seen those with more 'psychotic anxiety' both as a result of ptsd and as a stand-alone disorder, respond to this type of treatment. Other antipsychotics in these cases tend to be heavier handed to a well-functioning outpatient, and Abilify can sometimes fit the bill.

A similar thing can be said of the borderline. While traditionally difficult to treat, using antipsychotics in borderlines to help control mood dysregulation is nothing new. Again, assuming that you don't chase the patient away with akithesia from low-dose abilify (a common finding for me), it can help with impulsivity in some cases? Is there empirical research for this? Probably not. But with some patients (particularly borderlines), it's more about putting out chronic fires than complete "recovery" or remission.

I'd be interested to hear what other docs think too.

 

[TheWowEffect]

I agree with Anasazi. Treating many patients is not as cut and dry as you are making it out to be. Standard of care for borderline patients is to treat specific symptoms, be it with a small dose of Abilify or something else.

I am a big believer in maximizing antidepressant doses quickely. However, we all know that SSRI take time for the full effect. I see no harm in augmenting with Abilify, seroquel etc. in the acute phase of anxious/agitated depression to give a patients immediate relief. Of course, not every patient gets akathisia or EPS.

I don't think you need a study to compare anything to Buspar. Mere clinical experience can teach us a lot about effectiveness or ineffectiveness of certain meds.

 

[kugel]

I'm seeing a lot of patients coming in with Abilify for depression, who have no idea why it was chosen. When I tell them it's an antipsychotic, they flip out a bit. When we talk about the options (like maximizing the AD, revisiting the dx, exercise/lifestyle/sleep hygiene, switching AD's, adding another AD, stopping ETOH/drugs, etc, etc) they almost always choose one of the simpler options (usually max. the AD or change AD or treat under-treated anxiety).

Granted, I probably "sell" the options I prefer, and I greatly prefer NOT to spend hundreds (or more) of gov't, patient, insurance money on one of my least favorite options.

But few depressed pt's seem to choose Abilify when provided a number of options.

As an antipsychotic, I have no problem with Ability except the cost.

 

[whopper]

However, we don't know if that same patient had an untoward side effect which required a dose lowering (sexual side effect, etc), and that the abilify if being tried as an augmenter.

Fair question. No-this person had no side effects to the Zoloft.

 

[MBK2003]

I totally agree with Whopper on seeing this trend, also in C&A psychiatry. Given the recent data on atypical antipsychotic associated weight gain, I've redoubled my effort to help the adolescent and family decide on treatment alternatives that carry lower long-term risk. I've also noticed that I see lots of people with "treatment-resistant depression" admitted to the inpatient unit on Abilify & Lexapro, with no previous trials of any other SRI's or STAR*D/other acceptable augmentation strategies (lithium, anyone??).

 

[whopper]

Given the recent data on atypical antipsychotic associated weight gain, I've redoubled my effort to help the adolescent and family decide on treatment alternatives that carry lower long-term risk

Abilify is metabolically neutral, though the combined ADA/APA guidelines say to do metabolic lab testing--even if its Abilify or Geodon.

However, and you get the point--why Abilify 5mg when there's others meds for cheaper that do not need lab testing such as Buspirone?

 

[Regnvejr]

Abilify is metabolically neutral, though the combined ADA/APA guidelines say to do metabolic lab testing--even if its Abilify or Geodon....

Well, kind off. Geodon fits that better than Abilify. I have had both weight gain and weight loss on Abilify. On average, it is neutral 😉 Geodon has been weight neutral, but I have had several cases where blood sugars went up, even when rechallenged. I have yet to see that with abilify (which also gives more Akasthisia and nausea but only rarely sedation).

So you still need the metabolic follow-up. Geodon especially for the sugars and Abilify especially for the lipids. No free lunch.

Regardless, using any of them in kids is complicated. 1/3 of kids and 1/5th of adolescents seem to have paradoxical aggitation on dose increases of Abilify, BTW. Aggitation that doesn't resolve with lowering doses, I have to stop it completely to resolve it.

And in kids, Geodon seems to have some cognitive dulling, though less than Seroquel, and a lot less than Risperidone. Why Risperidone was ever approved for Autism is beyond me.

 

[kugel]

No free lunch.

No free lunch
No free lunch
No free lunch

This is the most important rule in medicine!

It is essential that every provider, in any field, repeat this mantra as per the prescription:
"repeat orally x3 q arrival of drug rep"