Thoughts on Abilify

[softballtennis]

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I know that it's a very good medication for psychosis and bipolar but only works 11 percent better when treated with an anti-d. Patients also have less of a risk developing metabolic syndrome and gaining weight as opposed to Zyprexa. I think in general it is a good medication but the cost is outrageous it's 935+ for this medication.

 

[whopper]

Mentioned this before. There's plenty of antidepressant augmentation agents around for about $4 such as buspirone. Others may not be $4 but are much cheaper such as a pretty much any low dose atypical, thyroid hormone, fish oil, etc.

Abilify's got the market only because of the sexy 25 year old drug rep is hawking it.

 

[vistaril]

Mentioned this before. There's plenty of antidepressant augmentation agents around for about $4 such as buspirone. Others may not be $4 but are much cheaper such as a pretty much any low dose atypical, thyroid hormone, fish oil, etc.

Abilify's got the market only because of the sexy 25 year old drug rep is hawking it.

well that and medicare(and thus commercial insurers piggyback that) pays for it for some dumb reason.

It's kind of like Virginia College or 4th tier for profit law schools. Are they educational options that are good in any way? Of course not. They are a failure in every respect, producing a terrible product for the price and terrible outcomes for its graduates. So why are they in existence and so common? Because for some dumb reason, the federal govt subsidizes the hell out of them with virtually unlimited student loans......creating a totally artificial market for these places.

Same thing with abilify.....if medicare and commercial insurers simply said there is not any data to support paying 300 dollars per month(or whatever they reimburse) for this med and stopped paying for it, then there would be no market for this drug. NONE. Literally zero prescriptions would be written or filled.

 

[TexasPhysician]

In my patient population Abilify is a horrible med for bipolar/psychosis comparatively. I almost never use it in adult populations for acute stabilization.

 

[notdeadyet]

I had to fight for prior auth for Abilify Maintena and discovered that it's $1800/month. Wow...

 

[MiddleRoad]

Also, had a young patient who had gained 50+ lbs in a few months on Abilify as augmentation. My attending was puzzled because of the reputation for little to no metabolic side effects when compared to other atypicals. With a little research, I found a large review and several papers that showed when it's used as an adjunct with antidepressants there is a significant risk for weight gain (more comparable to zyprexa-like gains), but most people don't know this when they use it as a secondary medication for depression.

 

[whopper]

Abilify IMHO is only worth a try in new onset cases, and in such cases there is not so much damage to the brain, cases where it's known to work very well. If it works, great. No sedation, low chance of weight gain, great. Schizophrenics being so for decades with lots of noncompliance? I've never seen it work well. It's also not a very efficacious med, being one of the lowest efficacy antipsychotics in CATIE with only Seroquel being weaker.

For antidepressant augmentation? It's pretty much a last end choice. There's several $4 meds (e.g. buspirone, low dose lithium), several other meds that are not $4 but much cheaper than Abilify such as thyroid hormone, Lamictal, and they got more data and are safer (well not lithium, but the others are), and others that are OTC such as fish oil.

IMHO there's no reason to start anyone on Abilify for antidepressant augmentation except last-line. We're talking about a med that's hundreds of dollars/month vs a $4 one and likely being being safer. Even by then the patient is likely in a situation where ECT is needed.

Even if the person needed an antipsychotic for MDD with psychotic features, why not just give another atypical? Risperdal, Geodon, and Zyprexa are now generic and also have strong data showing they work for antidepressant augmentation at low dosages.

 

[vistaril]

Abilify IMHO is only worth a try in new onset cases, and in such cases there is not so much damage to the brain, cases where it's known to work very well. If it works, great. No sedation, low chance of weight gain, great. Schizophrenics being so for decades with lots of noncompliance? I've never seen it work well. It's also not a very efficacious med, being one of the lowest efficacy antipsychotics in CATIE with only Seroquel being weaker.

For antidepressant augmentation? It's pretty much a last end choice. There's several $4 meds (e.g. buspirone, low dose lithium), several other meds that are not $4 but much cheaper than Abilify such as thyroid hormone, Lamictal, and they got more data and are safer (well not lithium, but the others are), and others that are OTC such as fish oil.

IMHO there's no reason to start anyone on Abilify for antidepressant augmentation except last-line. We're talking about a med that's hundreds of dollars/month vs a $4 one and likely being being safer. Even by then the patient is likely in a situation where ECT is needed.

Even if the person needed an antipsychotic for MDD with psychotic features, why not just give another atypical? Risperdal, Geodon, and Zyprexa are now generic and also have strong data showing they work for antidepressant augmentation at low dosages.

unfortunately though, we are in a system where most patients don't actually pay for abilify themselves. A great number of patients taking abilify are on medicare/Medicaid. The ones on Medicaid literally pay a dollar for abilify. IMO it is a travesty that Medicaid covers abilify. If the pts have no skin in the game, why shouldn't they demand abilify?

Even commercial insurance patients may have copays as low as 25 dollars for abilify. So not a huge deal for them either.

 

[notdeadyet]

A great number of patients taking abilify are on medicare/Medicaid. The ones on Medicaid literally pay a dollar for abilify. IMO it is a travesty that Medicaid covers abilify. If the pts have no skin in the game, why shouldn't they demand Abilify?

They don't demand it. And if they do, it doesn't mean you prescribe it. No more than you do when they demand Ambien, benzos or norco. That's silly....



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[vistaril]

They don't demand it. And if they do, it doesn't mean you prescribe it. No more than you do when they demand Ambien, benzos or norco. That's silly....



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sure some patients demand it. They see the commercials and then tell their psych or pcp that they want it.

 

[twright]

Also, had a young patient who had gained 50+ lbs in a few months on Abilify as augmentation. My attending was puzzled because of the reputation for little to no metabolic side effects when compared to other atypicals. With a little research, I found a large review and several papers that showed when it's used as an adjunct with antidepressants there is a significant risk for weight gain (more comparable to zyprexa-like gains), but most people don't know this when they use it as a secondary medication for depression.

Not surprising...
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0055102/

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[whopper]

A great number of patients taking abilify are on medicare/Medicaid. The ones on Medicaid literally pay a dollar for abilify. IMO it is a travesty that Medicaid covers abilify. If the pts have no skin in the game, why shouldn't they demand abilify?

If they demand it, I tell them why I wouldn't want it as a first line augmentation agent if it were me. Most patients understand and even despise the commercial influence on medicine. If this really is a major problem in your clinical scenario (certain demographics tend to show repeated behavioral traits), take the time to photocopy the STAR*D study regarding augmentation, and emphasize that with the other non-antipsychotic augmentation agents, there is no risk of EPS or TD.

This is one of those times where I actually am glad there are prior authorizations for a lot of meds needed, and if I were a doc-advisor for an insurance company, I'd make them require a PA for it with at least three tries of alternatives before Abilify was used.

 

[softballtennis]

Mentioned this before. There's plenty of antidepressant augmentation agents around for about $4 such as buspirone. Others may not be $4 but are much cheaper such as a pretty much any low dose atypical, thyroid hormone, fish oil, etc.

Abilify's got the market only because of the sexy 25 year old drug rep is hawking it.

I agree with you it's just nonsense that some patients believe the lies of the drug reps. Most people I know on Abilify are on it for anti-d augmentation since that's what it's advertised for , most people don't know it's a anti psychotic that treats schizophrenia and etc. I think it's a good med because it promotes little risk of metabolic syndrome but Geodon and Invenga also carry little risk of metabolic syndrome and they are also less pricey.

 

[shan564]

In my patient population Abilify is a horrible med for bipolar/psychosis comparatively. I almost never use it in adult populations for acute stabilization.

I've heard a lot of people tell me this, and so I always avoided it, until a patient told me that she seems to think that it's the only thing that has worked for her. She was actively manic/psychotic, so we figured that it was probably just a coincidence that she got better at the same time as Abilify was started in the past, so we didn't think that it was the best idea. But then after poor response to haldol and confirmation from her family that Abilify did work for her, the medical student dug up a bunch of studies in which it worked well. I didn't buy it because of all of the negative things I've heard... I had previously found the same articles a couple of years earlier when I was a student, and an attending had dismissed it by saying something like "yeah, I know that's what the research says, but it just doesn't seem to work that well," so I took his advice and formed my opinions of Abilify based largely on that. This time around, the attending agreed to try it based on the student's articles and the family's insistence. We switched her over and she improved pretty rapidly. I felt pretty dumb for not starting it right from the start. The attending and I were both pretty surprised at the extent to which she responded.

Since then, I've seen it work for a lot of people who didn't respond well to other antipsychotics. As you guys know, receptor profiles are a weird thing and we still have no idea why the weakest dopamine blocker (clozapine) works better than the stronger ones. And Abilify has a pretty unique receptor profile. My theory is that mania/psychosis and schizophrenia are actually heterogeneous illnesses and that different people have different neuroplastic/neurotransmitter defects that we haven't yet been able to characterize, which is why some people respond best to abilify (weird nonspecific receptor profile), some people respond best to zyprexa (weak blockade of multiple receptors), some people respond best to risperdal (strong dopamine blocker), etc.


But yeah, I definitely agree that it shouldn't be the first-line agent for augmentation. Aside from being expensive, it's not even the best evidence-based choice. Still, I'm looking forward to it becoming generic next year.