Thoughts on Abilify with Adolescents?

[medapplicant88]

Does abilify work for adolescent bipolar I disorder? Like monotherapy abilify.

or for adolescent schizophrenia?

Are there better antipsychotics out there?

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[Chimed]

Abilify can be used in Adolescents for either Bipolar DO or Schizophrenia/Psychosis. I typically start with Abilify or Geodon because they are less likely to cause metabolic issues. HOWEVER, Abilify can definitely cause weight gain in adolescents, probably more so then in adults. Regarding efficacy, the jury is still out. But for now, assume that all the atypicals work the same. Like adult patients, it really comes down to side-effect profile. But in clinical practice, if an adolescent has REAL Bipolar DO (not just emotional dysregulation that a lot of child psychiatrists are calling bipolar disorder...that's another story 🙄), then I have a low threshold for moving toward good'ole Lithium. Also, clinically, I haven't been that impressed with Geodon for psychosis, but I've seen Abilify work pretty well.

 

[billypilgrim37]

Correll CU, Sheridan EM, DelBello MP. Antipsychotic and mood stabilizer efficacy and tolerability in pediatric and adult patients with bipolar I mania: a comparative analysis of acute, randomized, placebo-controlled trials. Bipolar Disord. 2010 Mar;12(2):116-41.

In general, atypicals have better data and are more effective than traditional mood stabilizers for pediatric bipolar. And yes, Chimed concerns about diagnosis are paramount as well, but these studies have fairly rigorous methods for diagnosis. Bob Findling and John Calabrese have a series of papers comparing various iterations of depakote and lithium in pediatric bipolar, and depakote consistently looks a teensy, insignificant amount better than lithium. Kowatch and Findling's 2000 paper comparing effect sizes generally puts depakote > lithium >> tegretol. None of these papers talk much about lamotrigine, unfortunately.

 

[whopper]

Thanks for the above data. I've never known of good sources of data on child-patients with these meds.

I'm finding Lamotrigine possibly being under-utilized.

No labs, no incredible amounts of weight gain, possible iatrogenic weight loss (that many patients welcome)...

Yes there's the Stevens Johnson Syndrome but if the patient takes it right, they'll notice a rash first and stop the med just like you the physician should warn them about.

I've found Lamotrigine a good choice for patients with problems affording medications. Some places sell the 100 mg tabs of it for only about $20 for a month's supply. While Lithium and Carbamazepine are only $4 a month, they also require labwork on the order of costing hundreds of dollars every few months.

Abilify can definitely cause weight gain in adolescents, probably more so then in adults. Regarding efficacy, the jury is still out.

I've noticed in my anectdotal experience that there is a subgroup of patients that oddly gain weight from it. From that experience, and only on adults, I've noticed it being on the order of effifacy as Geodon and Seroquel (that were rated as lower in efficacy in CATIE), but also noticed that there are patients it works well with and those same patients also don't have to suffer from weight gain, sedation, and sexual side effects. In short, if you want to try a med where the patient may have a fair shot of lesser side effects (if any), this is worth a try.

I've also noticed that there's a subgroup of patients that tend to get akithesia and EPS quite strongly with Abilify.

I asked a prominent researcher from the NIMH if they planned on doing a new CATIE study involving the newer atypicals that weren't included in the original CATIE. He told me that unfortuantely that was extremely unlikely to happen.

 

[MiesVanDerMom]

My son was on Abilify when he was 4 for Bipolar. It worked initially and then wore off. I found him a new psychiatrist when he was 5 who was willing to give Lamictal a try and it has been great. I've been surprised on my child psych rotations that it isn't used more often.

 

[whopper]

A doctor once told me...
"You know why hydrochlorothiazide is the top prescribed blood pressure med?"

Me: "no, why?"

Doctor: "Because the doctor only has to write "HCTZ" and not P-R-O-P-R-A...."

While this may sound silly, I believe there is truth to it.

Lamictal is generic, so drug reps don't hawk it.

Many doctors don't have the patience to write ever increasing dosages of it during the taper up phase, nor do they want to explain Stevens Johnson Syndrome. (From my anectdotal experience, less than 20% actually talk about side effects with patients). Heck, the IM doctor on my unit will only work on patient if the nurse gets the chart for him, puts it in front of him and then opens the chart to the page he wants, all the while he sits down and stares at her with a cold look, I kid you not.

And if a patient is already on Depakote, it's going to be a heck of a transition from Depakote to Lamictal during outpatient because both meds can interact in a dangerous manner.

What I've been doing is I start the patient on a treatment for bipolar that will treat the symptoms in the here and now and put them on a Lamictal taper-up. Once the Lamictal reaches 200 mg Qdaily (if not more) then I taper down the other med. Why? As I mentioned above, no need for labs, usually no weight gain, sometimes iatrogenic weight loss, usually no zonked-out feeling (that usually accompanies Depakote, Seroquel, and Zyprexa), no EPS.

You have to shop around for the cheap 100 mg tablets. I had a patient with bipolar disorder who had to pay for everything out of pocket and he did not make much money. I called up 5 pharmacies and found Krogers (a grocery chain in the midwest) had the Lamictal at 100 mg at about $20 for 30 pills if I remember correctly. I also recall them selling the 200 mg tablets for far more than 2x the price of the 100 mg tabs. He could not afford the labwork needed for Lithium or Carbamazepine.

The Lamcital worked very well for him and he ended up only paying $40 a month for it. Far better than the $750 he would've had to pay for Abilify. Think about it. Even if the guy had insurance and we know the cheaper med could work, we should go for it. It saves money to over already overpriced system. If all doctors did this I would not be surprised if it ended up saving the system hundreds of millions of dollars if not possibly billions.

I am sometimes amazed at the lack of effort on the part of physicians to try to find an affordable medication for their patient, like one of my other patients who's doctor put her on Lexapro 40 mg a day for bipolar disorder (and why is that idiot doctor giving Lexapro for bipolar disorder and at 40mg, over 2x the manufacturer's maximum recommended dosage?) that she had to pay for out of pocket (Ever hear of Citalopram?) and I sometimes wonder WTF is going on with these doctors but that's getting OT.

 

[kugel]

A doctor once told me...
Even if the guy had insurance and we know the cheaper med could work, we should go for it. It saves money to over already overpriced system. If all doctors did this I would not be surprised if it ended up saving the system hundreds of millions of dollars if not possibly billions.

Thank You, Whopper.
My auto mechanic does this for me, my plumber does this for me, why not my doc? When they show an effort to use a cheaper part that will work fine, I am then more than willing to pay their labor rate, and to call on them in the future.

It's quite common these days for patients who do have insurance to periodically have to switch insurance co's and sometimes to be without insurance. If you put a pt. on an expensive med which just happens to be on the preferred formulary of one insurance company (including a Medicaid or VA formulary), it is likely to be unavailable on other formularies. If I start the pt on a cheaper med from the outset, there is less likelihood that he'll ever have to switch or go without meds due to financial concerns. And even when the patient has good, stable private insurance, the total private+public healthcare "budget" is a finite resource. Money that I cause to be needlessly sucked out of the system is going to cause others to have to pay more or else go without. In the public system, there is no doubt that every dollar I spend on this patient is a dollar I won't have to spend on someone else's treatment. That's just the reality. In the vast majority of cases, there is either no information as to what will be "the best" med for any particular patient, or there is little/no difference in efficacy. As long as the potential side-effect burden is not dramatically different, why not try the cheaper (overall cheaper, not just cheaper copay) medicine? When I explain this to pt's (it only takes ~ 20 seconds), they are overwhelmingly agreeable to it.