I was wondering if anyone has any experience on this? I know for psychosis and mood instability, it takes a few weeks. I have a client taking an SNRI and i want to add it as an adjunct to improve depressed mood as well as passive SI.
How long does it take Latuda to kick in as an adjunct to treating MDD?
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Atypical Antipsychotic Augmentation for Treatment-Resistant Depression: A Systematic Review and Network Meta-Analysis
Study duration was 4-12 weeks.
Also bear in mind that there's no data I'm aware of showing that Latuda is better than the other atypicals and it's price is very high. In short I don't see a reason to give it over other atypicals for antidepressant-augmentation unless there's something more specific going on. We're talking a med that's $1280/month vs one that's $7 to 112/month (depending on the pharmacy) with no significant superiority of the more expensive med vs the cheaper one on an initial try. Risperidone is available generic and can be tried at 1 mg or less.
Study duration was 4-12 weeks.
Also bear in mind that there's no data I'm aware of showing that Latuda is better than the other atypicals and it's price is very high. In short I don't see a reason to give it over other atypicals for antidepressant-augmentation unless there's something more specific going on. We're talking a med that's $1280/month vs one that's $7 to 112/month (depending on the pharmacy) with no significant superiority of the more expensive med vs the cheaper one on an initial try. Risperidone is available generic and can be tried at 1 mg or less.
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Depending on the situations it seems like we’re actually able to get coupons or free samples to our patients in the above situation. At least while things are still brand new. People seem to respond really well to Latuda, can’t wait for it to become generic.
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Relative lack of metabolic side effects seems a good enough reason to me.
Last I checked patent is up in 2019. Until then, it is stupidly expensive. I don't plan to write it until there's a generic for sure.
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Well it does have a good patient assistance program and is actually on many formularies at least for bipolar depression. Covered at tier 1 under Medicaid in my state. That's due to paucity of treatments with this indication. Also keep in mind that studies showing positive outcome at certain times are telling you when treatment statistically separates from placebo. Clinically, many people start feeling better right away when any strategy for depression treatment is initiated. This may be placebo effect, but I never tell a patient a treatment won't start working for X amount of time. That may cause a nocebo effect. I do say that we won't judge it ineffective until there is an adequate trial.
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Interestingly lurasidone is also in Phase III trials at the moment for an MDD indication, so expect to see Latuda XR or some other goofy formulation in the near future.
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Not bad reasons but let me address some of the above.
1)
OK it's not the same thing but the business strategy is the same. (Yes of course addiction is bad and not what we're talking about). Ziprasidone, for example-cost $25 to 150 depending on the pharmacy per month, NO METABOLIC SIDE EFFECTS. Why not try that one instead of a med where the coupons only last for a few months, the samples can only be given for days to weeks tops, then they or the system is paying over $1000/month?
That's entire reason why the company is giving you samples in the first place-to get them on an expensive medication and not want to change their minds once on it and that's a reason why the cocaine business strategy analogy isn't totally off (it's somewhat off but the point is the same). It's the same reason why the government started adding regulations to pharm reps who gave free pens, weights, clocks, ties, etc to docs with the med's logo printed on it.
I'm not arguing we go cheap and not give out the good expensive meds. I'm arguing why give out the expensive meds that are not found to be superior first instead of giving out the cheaper meds that work just as well first? (Of course give the expensive stuff out for a try if the cheaper stuff doesn't work).
2) No or reduced metabolic side effect profile.
Again no atypical demonstrates clear superiority here in anitdepressant augmentation. There are other atypicals with favorable metabolic side effect profiles such as Ziprasidone or Aripirprazole.
3)
4) Why even go the atypical route when there's plenty of other cheap meds that are actually in general safer than atypicals that are highly effective as antidepressant augmentation meds? E.g. Buspirone, an antidepressant of a different mechanism, Lamotrigine, thyroid hormone?
1)
That's the free cocaine strategy. Give cocaine-free samples, then once they're hooked now they're addicted they're going to be in the palm of the drug-dealers hand for life.
OK it's not the same thing but the business strategy is the same. (Yes of course addiction is bad and not what we're talking about). Ziprasidone, for example-cost $25 to 150 depending on the pharmacy per month, NO METABOLIC SIDE EFFECTS. Why not try that one instead of a med where the coupons only last for a few months, the samples can only be given for days to weeks tops, then they or the system is paying over $1000/month?
That's entire reason why the company is giving you samples in the first place-to get them on an expensive medication and not want to change their minds once on it and that's a reason why the cocaine business strategy analogy isn't totally off (it's somewhat off but the point is the same). It's the same reason why the government started adding regulations to pharm reps who gave free pens, weights, clocks, ties, etc to docs with the med's logo printed on it.
I'm not arguing we go cheap and not give out the good expensive meds. I'm arguing why give out the expensive meds that are not found to be superior first instead of giving out the cheaper meds that work just as well first? (Of course give the expensive stuff out for a try if the cheaper stuff doesn't work).
2) No or reduced metabolic side effect profile.
Again no atypical demonstrates clear superiority here in anitdepressant augmentation. There are other atypicals with favorable metabolic side effect profiles such as Ziprasidone or Aripirprazole.
3)
It could be Lurasidone is going to be superior vs other atypicals with depression, but so far, at least as far as I know, the data isn't available to us yet. Also I've given a few dozen patients Lurasidone for Bipolar-Depression and I'm not seeing any where close to the success in the studies. I've only so far see maybe 2-3 patients get better with it who had Bipolar Depression. Maybe others here have a different experience?
4) Why even go the atypical route when there's plenty of other cheap meds that are actually in general safer than atypicals that are highly effective as antidepressant augmentation meds? E.g. Buspirone, an antidepressant of a different mechanism, Lamotrigine, thyroid hormone?
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Bingo.
D
deleted736562
Isn't the evidence for atypicals the best out there? My first choice is usually Abilify cause it also seems the most supported among the atypicals.
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The patients in our clinic can not afford the 4$ list at Walmart, they can’t afford $12 for lexapro, so they put up with 5 years of coupons and if need be we switch them to something else. But we also have a certain list of newer tier medication that we are able to obtain for our patients for free, and if the alternative is to take nothing, I’m doing it. And keeping people out of the hospital while doing it.
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This is for patients who participate in our PAP program. Of course with our normal insurance patients and in general those who do not qualify, we use an approach such as you guys are describing.
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Disordered Doc-I've been in that same boat and in your situation it makes complete sense.
Further I've had some good pharm reps that went out of their way to make sure we could get plenty of samples indefinitely. Again makes sense there. It just annoyed the heck out of me that they'd walk out of the office with like 20 boxes of meds cause those samples come only a few a box.
Abilify had tons of buzz cause the company that made it was the first to push an atypical for augmentation and business-wise it worked despite that the data was clearly out there that it was no where close to the first, nor better, and it was being sold at costs of $800+ a month when Buspirone was $4-10 a month, safer, and even had more data backing it's use. It also got a spotlight cause former tradename only meds such as Risperdal, Zyprexa, Geodon, etc had all become generic and the pharm reps stopped ramming it down our throats, so it became one of the lone meds with high commercial bells and whistles.
The success of it did lead to more company sponsored studies and more interest among even neutral researchers so it does have more data than others, but again no data showing superiority over others. Further the mechanism by which it works is the same as other atypicals. So in a debate I do completely admit it has a leg to stand on as a "first" atypical for augmentation, but I'd still argue not to try atypicals first for augmentation unless there's MDD with psychosis. Also to add to that "leg" Abilify usually is weight-neutral (in a small percentage it causes incredibly bad weight-gain but the odds are very small), further pointing to it as not a bad choice. Also now (but not back in the paragraph I mentioned) it's generic though still an expensive generic at some major pharmacies (over $500), but at others it's $20 or less.
Again, if the expensive med is the better med for the patient by all means prescribe it but also by all means don't try it first over the cheaper med that's just as good, possibly even better.
Further I've had some good pharm reps that went out of their way to make sure we could get plenty of samples indefinitely. Again makes sense there. It just annoyed the heck out of me that they'd walk out of the office with like 20 boxes of meds cause those samples come only a few a box.
Abilify was the one med most touted by the pharm reps but again it showed no superiority vs other augmentation agents to my knowledge. Further the data for the other augmentation agents is quite rich and was done in the STAR*D that hands-down pretty most all of us would agree was one of the best studies in psychiatry in the decade.
Abilify had tons of buzz cause the company that made it was the first to push an atypical for augmentation and business-wise it worked despite that the data was clearly out there that it was no where close to the first, nor better, and it was being sold at costs of $800+ a month when Buspirone was $4-10 a month, safer, and even had more data backing it's use. It also got a spotlight cause former tradename only meds such as Risperdal, Zyprexa, Geodon, etc had all become generic and the pharm reps stopped ramming it down our throats, so it became one of the lone meds with high commercial bells and whistles.
The success of it did lead to more company sponsored studies and more interest among even neutral researchers so it does have more data than others, but again no data showing superiority over others. Further the mechanism by which it works is the same as other atypicals. So in a debate I do completely admit it has a leg to stand on as a "first" atypical for augmentation, but I'd still argue not to try atypicals first for augmentation unless there's MDD with psychosis. Also to add to that "leg" Abilify usually is weight-neutral (in a small percentage it causes incredibly bad weight-gain but the odds are very small), further pointing to it as not a bad choice. Also now (but not back in the paragraph I mentioned) it's generic though still an expensive generic at some major pharmacies (over $500), but at others it's $20 or less.
Again, if the expensive med is the better med for the patient by all means prescribe it but also by all means don't try it first over the cheaper med that's just as good, possibly even better.
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Modern medicine (any specialty):
Someone presents with fundamentally an axis II problem, is given a medication that may very modestly treat an axis I problem (or axis III if non-psychiatry field), but makes axis IV explode. And, if you wait long enough, will make axis III explode, too.
Someone presents with fundamentally an axis II problem, is given a medication that may very modestly treat an axis I problem (or axis III if non-psychiatry field), but makes axis IV explode. And, if you wait long enough, will make axis III explode, too.
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Fully admit that I’m still in residency and don’t yet have the n to back up anything with “in my clinical experience”. But I’ve been under the impression that abilify causes a heck of a lot more weight gain relative to what the reps used to tout; stating it was the newest kid on the block and weight neutral. Not as bad as your depakote or seroquel or clozaril. But still.
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And the good news is now we have Brexpiprazole, which exists clinically because... reasons.
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When it first came out it was advertised as metabolically neutral. That's not true.
But when it came out, as usual with new meds, it was only tested on a few hundred people tops. The metabolic issues with the med weren't detectable at that point but about 3 years later it did become apparent after it was given to millions of people. It's called Phase IV testing. It's a reason why I always cautioned residents to have some suspicion of brand-new approved meds.
Despite that Abilify isn't completely metabolically neutral (there's a small subset of the population where they will gain tremendous weight on it, it also can increase blood sugars), in general the overwhelming majority do not gain weight on it. It's to the degree where I tell patients not to worry about it unless they notice metabolic changes while on it within weeks of starting it....but if they do start, get them the heck off cause they could be in that small risk group of significant weight gain or warn the patients of the risks/benefits and tell them to decide while also telling them there's other options.
Also bear in mind when it came out, all the other atypicals were associated with heavy weight gain. The only ones out then were Clozapine, Olanzapine, and Risperidone. Abilify came out about the same time as Geodon. Abilify is still, metabolically, a better med to choose among the atypicals though as I mentioned some will have a bad experience with it.
It's called "evergreening."
Evergreening - Wikipedia
It's when a company gets a med, extends the patent, or uses an old med whose patent will expire, and then new make a new med out of it that is about 99% the same molecule and does the same thing and then advertise that med with hot pharm rep babes in their 20s...and it works market-wise. That's why it's done. Studies and real-life work shows that there's plenty of idiot doctors that'll fall for the new med just cause it's the one with the free lunch instead of prescribing based on a solid knowledge of meds (and their prices).
I have seen some "evergreened" meds that really do have some superiority. E.g. I've seen some patients do better on Pristiq vs Venlafaxine (although Pristiq these days is generic). I wouldn't be surprised if there will be a small subset of patients who get a better reaction with Rexulti vs Abilify but they are very similar medications, and definitely worth trying the cheaper one first unless later data shows Rexulti to be somehow significantly superior in some way....which at this point I don't see available now.
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Stahl says that on paper it should have better tolerability with the same level of effectiveness. In practice we all know it exists because Abilify was a goddamn cash cow.
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Yeah. In 2015 it was like the fourth highest medication for total healthcare dollars spent on it, despite being a very small share of the market.
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I think I remember reading that it was the single biggest moneymaker in terms of net revenue at one point.
D
deleted736562
To be fair though, Abilify is a quite a versatile drug with a more unique side effect profile than other antipsychotics AND it comes as an injectable. Some of that cash is #welldeserved.
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I'll just leave this here:
Can Aripiprazole Worsen Psychosis in Schizophrenia? A Meta-Analysis of Double-Blind, Randomized, Controlled Trials. - PubMed - NCBI
"Can Aripiprazole Worsen Psychosis in Schizophrenia? A Meta-analysis of RCTs"
Summary: not exactly, but does have a higher discontinuation rate after switching to it due to lack of efficacy.
Can Aripiprazole Worsen Psychosis in Schizophrenia? A Meta-Analysis of Double-Blind, Randomized, Controlled Trials. - PubMed - NCBI
"Can Aripiprazole Worsen Psychosis in Schizophrenia? A Meta-analysis of RCTs"
Summary: not exactly, but does have a higher discontinuation rate after switching to it due to lack of efficacy.
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I’ve become so biased against it. I don’t find it particularly helpful for psychosis and typically never use APs for depression. I see a lot of akathisia and, surprisingly, a lot more Parkinsonism with it.
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Medication efficacy is very patient specific cause it's very genetic specific whether it works or not.
Each medication has it's place. Just that with out limited data, we usually don't have very specific data to point out which is the better med on a first-time visit.
So again, if you're in a situation where you don't have reason to believe the more expensive med will work better on the first try don't use it and try the cheaper alternative. Emphasis on "work better." If this were 5 years ago when Ziprasidone and Aripiprazole were not yet available as generics and the patient needed an antipsychotic and didn't want to gain weight I would consider them first-line despite that it's price back then was more than adding a zero to the current price.
Aripiprazole definitely does have advantages over other antipsychotics for those that respond well to it. Its much more metabolically neutral, it used a different mechanism, and wasn't sedating for the overwhelming majority, but we don't know nor never really know if it'll work well in a patient until they actually try it. Studies only tells us what it does in populations, not the specific individual.
My point is you have a patient where there's a $1200 med/month vs a $30 med/month and there's no reason to think the more expensive med will work better why give it out? There really is less than none cause you should be giving out the cheaper one first.
Each medication has it's place. Just that with out limited data, we usually don't have very specific data to point out which is the better med on a first-time visit.
So again, if you're in a situation where you don't have reason to believe the more expensive med will work better on the first try don't use it and try the cheaper alternative. Emphasis on "work better." If this were 5 years ago when Ziprasidone and Aripiprazole were not yet available as generics and the patient needed an antipsychotic and didn't want to gain weight I would consider them first-line despite that it's price back then was more than adding a zero to the current price.
Aripiprazole definitely does have advantages over other antipsychotics for those that respond well to it. Its much more metabolically neutral, it used a different mechanism, and wasn't sedating for the overwhelming majority, but we don't know nor never really know if it'll work well in a patient until they actually try it. Studies only tells us what it does in populations, not the specific individual.
My point is you have a patient where there's a $1200 med/month vs a $30 med/month and there's no reason to think the more expensive med will work better why give it out? There really is less than none cause you should be giving out the cheaper one first.
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