Any experience switching from olanzapine to abilify?

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mlk3454

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Hello, long time lurker, first time poster.

I am pharmacy student on an elective consulting rotation. I have been tasked the last 5 weeks with lowering pts copays (tier 3 drugs moved to tier 2 or 1) by switching from brand to generic or cutting doube strength tabs in half etc. We received a call from an MD asking our advice on switching a pt. from olanzapine to abilify. They are asking about the switch because the pt. can't afford the olanzapine and the doctor can give them coupons for abilify. He has never made the switch and wanted some opinions. The overseeing pharmacist and myself have looked up charts but there is no clear switch between antipsychotics.

I am hoping to see if anyone has any clinical experience making this switch or something similar that can aid in our help for the pt. in question. Thanks!

Double posting in psych for more exposure if ok.

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Hello, long time lurker, first time poster.

I am pharmacy student on an elective consulting rotation. I have been tasked the last 5 weeks with lowering pts copays (tier 3 drugs moved to tier 2 or 1) by switching from brand to generic or cutting doube strength tabs in half etc. We received a call from an MD asking our advice on switching a pt. from olanzapine to abilify. They are asking about the switch because the pt. can't afford the olanzapine and the doctor can give them coupons for abilify. He has never made the switch and wanted some opinions. The overseeing pharmacist and myself have looked up charts but there is no clear switch between antipsychotics.

I am hoping to see if anyone has any clinical experience making this switch or something similar that can aid in our help for the pt. in question. Thanks!

This was originally posted in the pharmacy section but thought there would be more clinical experience here.
 
There is no dosing equivalency between olanzapine and Abilify. Also, olanzapine is a much more potent antipsychotic, so bear in mind that Abilify may not control a pt's symptoms as well as olanzapine (if your pt has a thought disorder).
 
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I understand there isn't a cut and dry conversion. The doctor is looking for some ideas or help regarding the switch. I did find an older (albeit not the best) article but would like to hear some personal experiences on the matter. I dont always hold articles such as this as high as what is actually seen in practice.

*edit* I dont know what the pts dx is but I am assuming schizophrenia
 

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Was this a poorly trained psychiatrist or a PCP who thinks he can do things he has no business doing? Because that's a pretty terrible question for a doctor to be throwing at a pharmacist. And a question you would have no business answering without knowing the diagnosis and a lot more information.

What's the conversion between an apple and a banana? It's the same question. An apple is no more similar to a banana than olanzapine is to aripiprazole. They're both fruit. They're both antipsychotics.

The FGAs are more similar in the their MOA that you can say more (maybe converting Red Delicious to Jonagold?), but not SGAs.
 
You mean Abilify works???:D
 
It is definitely a PCP doing the dx/tx. So you can see my predicament as well...that said, are there any resources (very little in pubmed that I have found and most is supported by a drug company) that you can recommend to help him with his decision?

I understand there are differences but he seems pretty bent on making the switch as he is afraid that the pt will go from treated on zyprexa to nothing due to financial reasons; hence the abilify coupons.

I am loving the speedy responses :xf:
 
are there any resources... that you can recommend to help him with his decision?

www.epocrates.com

Abilify
aripiprazole
Dosage forms: 2,5,10,15,20,30; 1/mL; IM

bipolar disorder, manic/mixed
[monotherapy]
Dose: 15 mg PO qd; Start: 15 mg PO qd; Max: 30 mg/day; Info: for acute and maint. tx; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC

[valproate or lithium adjunct]
Dose: 15 mg PO qd; Start: 10-15 mg PO qd; Max: 30 mg/day; Info: for acute and maint. tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
 
www.epocrates.com

Abilify
aripiprazole
Dosage forms: 2,5,10,15,20,30; 1/mL; IM

bipolar disorder, manic/mixed
[monotherapy]
Dose: 15 mg PO qd; Start: 15 mg PO qd; Max: 30 mg/day; Info: for acute and maint. tx; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC

[valproate or lithium adjunct]
Dose: 15 mg PO qd; Start: 10-15 mg PO qd; Max: 30 mg/day; Info: for acute and maint. tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC

Thank you for this response. I have that as a resource. Lexicomp does a one up stating 7.5mg abilify is roughly equal to 5mg olanzapine.

Basically what I was hoping to get was some clinical experience (possibly with a reference) to back up Lexicomp and a couple papers similar to what I posted above. That said, any and all pertinent comments are welcome. :D
 
No takers?

I see in Lexicomp 7.5mg Abilify to be roughly equivalent to 5mg Zyprexa.
Any experience to back this up?
 
I've converted several patients from Zyprexa to Abilify in outpatient.

It's not a safe endeavor, but it's certainly something to consider, especially ifthe patient on Zyprexa is suffering from serious metabolic problems.

I do it slow. At a rate of about up to 5mg at a time per month, and hopefully with a team of people involved such as the patient's family, friends, and group home staff because switching a successful antipsychotic to another one will always involve risk, especially when you're switching from something relatively highly efficacious to something relatively lowly efficacious. I try to involve other people because often-times, when someone gets worse, they don't notice it themselves. I also do it slow so if someone worsens, hopefully it won't be by much and we can reverse-course before it gets real bad.

I always explain the risks and benefits to the patient and let them decide unless they lack capacity, in which case I let an independent person like a guardian, or, if no one else is available, I'll have to make the decision.

So far, I've converted, successfully, probably about 20 patients from Zyprexa to Abilify, and in many of those cases the person did actually better on Abilify I don't think it's because Abilify is somehow more efficacious than Zyprexa. In my opinion, it's not.

I've noticed some dynamics that I believe led to this high success rate. First, many short-term facility doctors know Zyprexa is highly-efficacious, and therefore use it as a first-choice in medicating a psychotic or manic patient. Remember, in a short-term facility, the economics favor getting the patient out ASAP. In many cases, if a patient is there longer than 4 days, the institution loses money. You bet that in these cases, a doctor is supposed to try to get a patient out ASAP, and that directs these doctors to use the big-guns first.

Some doctors also always pull out Zyprexa, without discriminating what is truly the best med for the patient. This is another factor that I believe led to me successfully crossing over several patients.

But in outpatient, if a patient is stable, they could stay in this treatment setting indefinitely--years. You have time to try other meds, and the economics don't work against you to get the patient out ASAP. I definitely think if you have a patient who is having metabolic issues, and having oversedation to try to switch from Zyprexa to another antipsychotic, but only in a controlled manner.

As for the patients who IMHO did better on Abilify, I believe it's because Zyprexa often zonks people out. Abilify often does not have this effect. Most of the patients I've converted often complained of confusion, problems staying awake, and other symptoms of being zonked in one way or another. While someone could've simply attributed that to negative symptoms, I believe it was due to side effects in most of the cases I've seen because like I said, Zyprexa is a more effective antipsychotic than Abilify. How could the less powerful med work better against psychosis in so many patients? IMHO it wasn't really working better, it was simply having less side effects.

In one group home, out of 25 patients, 21 of them were on Zyprexa or Seroquel. I attempted to convert all of them to Abilify or Geodon. Out of the 21, 17 successfully converted, and in the process were just as well or even better (likely due to less sedation), and dropped considerable weight and cholesterol in a beneficial manner.

1 lost weight but in a bad manner. He actually became underweight despite not having an eating disorder. I had to put him back on Zyprexa just so he'd eat enough again. What happened there I don't know. He's not depressed and just has no appetite off of Zyprexa, and even on that med he has poor appetite.

1 person definitely got worse, and after a trial on Abilify, Geodon, Risperdal, even with augmentation (lithium and Depakote) nope, she still didn't do well. Back to Zyprexa.

The other 2, I haven't noticed anything indicating things were better or worse after the switch.

I'd definitely think twice or not do a switch if the person has a history of treatment-resistant psychosis, a history of severe dangerousness while off of meds, and a lack of people who could observe the person during a switch.

In my forensic facility, I've noticed that not too many patients do well on Abilify. While I have no empirical data to back this up, I've noticed that patients ending up on a forensic psychiatric facility are often worse vs other psychotic or manic patients. Remember, these are people manic or psychotic to the point where they're arrested-often as a result of a behavior that's visibly very apparent as mental illness to those not skilled in treating it. In the forensic unit I work, I usually have to pull out the big guns, and even they're often not enough. I do try Abilify or Geodon, if the patient's stabilized, but if it doesn't work, I put them back on what did work.
 
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No takers?

I see in Lexicomp 7.5mg Abilify to be roughly equivalent to 5mg Zyprexa.
Any experience to back this up?

I usually see the agents cross tapered, starting new agent at lowest dose and then upward titrating. There isn't exact conversion with AAs, pts response differs between agents.

What happens when the coupons run out? The patient will just be switched again? Have they failed risperidone, usually the most cost-effective of the AAs and the most likely agent to be covered by third party.
 
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Good question on their insurance plan and what they have tried in the past. I dont know the whole story but am looking to give solid advice and make sure the doc understands the risks before pulling the trigger.
 
There is no dosing equivalency between olanzapine and Abilify. Also, olanzapine is a much more potent antipsychotic, so bear in mind that Abilify may not control a pt's symptoms as well as olanzapine (if your pt has a thought disorder).

In terms of potency, Zyprexa and Abilify are pretty much on par with one another; both are effectively dosed in the 10-30 mg range for schizophrenia and bipolar manic/mixed episodes.
 
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Dosage ranges are very similar between medications, and that does lend to some theory as to what is going on in a pharmacological manner.

But a patient doing well on Zyprexa 20 mg may or may not have any benefit whatsoever from Abilify at any dosage, and vice versa.
 
But a patient doing well on Zyprexa 20 mg may or may not have any benefit whatsoever from Abilify at any dosage, and vice versa.

Agreed...just clarifying that their potencies are roughly equal.
 
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From clinical experience, I've noticed it's not as effective as Zyprexa or Risperdal, is more likely to cause EPS vs Zyprexa or Seroquel (about roughly the same as Risperdal), has activating symptoms, despite the claims of it being metabolically neutral there is a subset of people that oddly gain lots of weight from it (though I've only seen this a few times out of several people on it), and is mostly activating though oddly in a small subset it causes sedation. I've rarely encountered anyone having prolactin type side effects from it.

Per the company, after I contacted them, they told me the activation effects were no longer apparent at dosages higher than 30 mg Qdaily. They told me at higher dosages, it loses it's partial dopamine agonism effect and becomes more of just a D2 blocker, though I've never felt the need to give it at a dosage higher than 30 mg Qdaily.
 
In terms of potency, Zyprexa and Abilify are pretty much on par with one another; both are effectively dosed within the 10-30 mg range for schizophrenia and bipolar manic/mixed episodes.

Yes, Abilify works but not as well for psychosis. Clinically speaking, it is nowhere near as effective as Zyprexa or Risperdal for psychosis.

In general, it is a good augmenting agent for depression and mild to moderate mood disorders.
 
I've had very good results with Abilify monotherapy (15-30 mg) in a case of disorganized schizophrenia and also bipolar disorder (mania w/ psychosis).
 
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We received a call from an MD asking our advice on switching a pt. from olanzapine to abilify. They are asking about the switch because the pt. can't afford the olanzapine and the doctor can give them coupons for abilify. He has never made the switch and wanted some opinions.

My recommendations:
A) Tell the PCP to get a psychiatry consult.
Switching from Zyprexa to Abilify is NOT like switching Celexa to Zoloft. Much more complicated, many more clinical dangers in possible relapse, many more changes in side-effect profile.

B) See A)

C) The patient can't afford Zyprexa, but probably can't afford the danger of such a switch without specialist oversight. Get a Psychiatry Consult.

D) See B)

In summation, Get a Psychiatry Consult.
 
I've had very good results with Abilify monotherapy (15-30 mg) in a case of disorganized schizophrenia and also bipolar disorder (mania w/ psychosis).

This does not make it as efficacious as Zyprexa or Risperdal. Of course, there is a subset of psychosis and mood disorder patients who can benefit from Abilily.
 
This does not make it as efficacious as Zyprexa or Risperdal. Of course, there is a subset of psychosis and mood disorder patients who can benefit from Abilily.

I never made such a claim (nor do I necessarily reject it), but please support your claim that Abilify is "nowhere near as effective as Zyprexa or Risperdal for psychosis".
 
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Do a quick review of the Cochrane databases and you'll find that in terms of effectiveness, zyprexa and abilify are the 2 best second gens. They also go on to say that zyprexa's effectiveness is marred by its severe side effect profile. you can almost tell that recommending abilify first line over all other choices is right on the tip of Cochrane's tongue.
 
We received a call from an MD asking our advice on switching a pt. from olanzapine to abilify. They are asking about the switch because the pt. can't afford the olanzapine and the doctor can give them coupons for abilify. He has never made the switch and wanted some opinions.

If price itself is an issue...

Risperdal is the cheapest atypical out there. Look into patient assistance programs for Zyprexa.

Loxitane, while being categorized as a typical antipsychotic, is only about $20 a month and is chemically similar in structure to Zyprexa. The upper pic is Loxitane, the lower is Zyprexa.

200px-Loxapine.svg.png


200px-Olanzapine.svg.png





and per some journals actually is an atypical antipsychotic.
Glazer WM: Does loxapine have "atypical" properties? Clinical evidence. J Clin Psychiatry. 1999;60 Suppl 10:42-6. Pubmed

It's just that it was developed before the the knowledge of what an atypical was, and while there is data showing that it's really an atypical, the categorizations never updated it.

Abilify isn't cheap and those coupon programs? The company could stop them or only provide temporary assistance--hence the lure to draw someone in to something the company hopes they won't get out of.

And of course, this must all be tempered with the knowledge that any switch to a new antipsychotic might not work.
 
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If price itself is an issue...

Loxitane, while being categorized as a typical antipsychotic, is only about $20 a month and is chemically similar in structure to Zyprexa. The upper pic is Loxitane, the lower is Zyprexa.

200px-Loxapine.svg.png


200px-Olanzapine.svg.png





and per some journals actually is an atypical antipsychotic.
Glazer WM: Does loxapine have "atypical" properties? Clinical evidence. J Clin Psychiatry. 1999;60 Suppl 10:42-6. Pubmed

It's just that it was developed before the the knowledge of what an atypical was, and while there is data showing that it's really an atypical, the categorizations never updated it.

Loxapine (loxitane) is not considered an atypical because in vivo its 5-HT2a occupancy does not exceed its D2 occupancy.

http://www.ncbi.nlm.nih.gov/pubmed/9356559

(Google: "PET exidence equipotent" for the full green journal article).

Interestingly, addition of cyproheptadine's 5-HT2a antagonism to loxapine could potentially tip the scales toward creating a "functional atypical".

www.ncbi.nlm.nih.gov/pubmed/9672060 (I couldn't find access to the full abstract).

In addition to the structural similarities you pointed out, clozapine is also structurally related to olanzapine and loxapine:

clozapine (below)
200px-Clozapine.svg.png




olanzapine (below)

200px-Olanzapine.svg.png


loxapine (below)
200px-Loxapine.svg.png



If I'm not mistaken, I believe that loxapine may also share unique pharmacologic properties with clozapine beyond just D2/5-HT2a antagonism. Perhaps someone more knowledgeable about this can comment.
 
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Hmm, interesting you brought up the in vivo and in vitro responses because the "newer" data (that's actually from the 90s) that argues to recategorize Loxapine is, yes, all in vitro. Thanks for that correction.

Seroquel, Clozapine, Loxitane, and Zyprexa all have a benzo ring in it. Per K&S, one approach to antipsychotic administration is if one antipsychotic is known to work (or not work), that may increase the likelihood that an antipsychotic of similar structure would work similarly.

Makes sense, after all, with receptor/lock and key theory this should be the way it is. Despite this, I haven't actually seen any empirical studies backing this up, though I do use this approach when recommending medications, among others (e.g. side effect profile, person's metabolic status, their ability to pay for the medication, etc). To make a study on this would be very difficult because you'd have to put someone on one med, and then try them on another if the med worked, hence putting the subject under the clinically uneeded risk of relapse of their symptoms.

On the other hand, there's a new branch of clinical labs that could be utilized based on the idea that genes govern receptor shape, and that based on a gene test, one could determine the best medication to give to the patient on the lock and key theory. I haven't seen too much with this clinically though some places do offer services in this area.
 
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I agree with the above post regarding moving to risperidone instead of abilify regarding cost issues. The abilify coupons seem like a typical ruse to pull people off of a drug like olanzapine (patent expiring this year I believe), onto abilify (patent runs through April 2015). Once the abilify coupons end what is the patient going to do...taper back onto olanzapine? This is stupid. Switching to risperidone is cheaper (but call the pharmacies first to find out I've seen ranges between $10/mo to $150/mo depending on pharmacy and their supplier) Loxapine is another interesting and inexpensive option. Though, if I was advising a family doctor, I would stick to the official atypicals to lessen concerns of liability, though not necessarily overall risk, regarding EPS, TD, etc.
 
My recommendations:
A) Tell the PCP to get a psychiatry consult.
Switching from Zyprexa to Abilify is NOT like switching Celexa to Zoloft. Much more complicated, many more clinical dangers in possible relapse, many more changes in side-effect profile.

B) See A)

C) The patient can't afford Zyprexa, but probably can't afford the danger of such a switch without specialist oversight. Get a Psychiatry Consult.

D) See B)

In summation, Get a Psychiatry Consult.

Absolutely agree. I'd hate to be in the court room when the PCP points over at you and said "well the pharmacist told me I could do X." You should wash your hand of this whole case, tell him he has no business making these changes of which he clearly has no conception and that you can't be a part of such substandard care.

Just because our licenses allow us to prescribe whatever we want doesn't mean we are qualified to do so. And this case is just asking for trouble.
 
This thread turned out to have a pretty good discussion!

That said, here is an update. The pt. is being treated for schizo and wont have insurance until the first of the year (2012). The doctor has a card for abilify that gives first fill free and $25 a month there-after. Quite interestingly (and also crossing the line) he prescribed the abilify to every member of this persons family so that he can get enough free fills to get him through the rest of the year. I shared the information with him and he graciously accepted and went along this path...
 
I have never been in a situation where I fudged on meds like the above, but sometimes the bureaucracy insurance companies put me through made thoughts like the above cross my mind. Not for me, but for patients. This was the exception, not the norm, but on occasion you get a patient where only the off-label med works, but now the company doesn't want to pay for it because it's off-label.

As for the Abilify, and all of the non-generic meds, there are patient assistance programs. Give them a try too, but be wary of programs that only offer assistance for a few months, then drop assistance completely. Those are basically stealth attempts to hook them in with honey and then charge them a killing later.
 
I would go with Kugel.
Get a psych consult. Perhaps for the PCP as well for putting his license in jeopardy by pulling such a stunt over 25 bucks a month.
 
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