Pretty much agreed. I tend to use it for people who are clearly manic by other symptoms and sleeping <2 hours a night and really starting to get themselves in trouble. After/as they stabilize I work on switching to something else (usually abilify.)
Still don't see the rationale compared to Seroquel which has so much evidence for being a great medication in bipolar disorder and is also very good at getting patients to sleep.
I agree for the outpatient bipolar 2 crowd, who present with depression and insomnia, and hx of hypomania. For acute mania, you can start Zyprexa 10 hs and quickly up to 20 if needed, where Seroquel you've gotta titrate a little slower and probably need to get up to the 400mg or more range to put the brakes on manic/hypomanic symptoms.
I don't find that people tolerate being put on antipsychotic doses of quetiapine all at once very well although tbh don't have a lot of experience doing so since my practice has not been to go to quetiapine for much of anything first line. If I have someone acutely manic I want them getting something potent that I know will have some effect at reasonably tolerated mania starting doses. I see little advantage to quetiapine over olanzapine long-term, they're both pretty bad as far as adverse effect profile, especially metabolic and sedation.
Correct. They both cause more weight gain than basically every other relevant maintenance option. I'm still going to try to switch someone to a med that won't make them (as) fat if they're stabilized on quetiapine, same as if they were stabilized on olanzapine.Adverse effect profile of seroquel seems to be better than olanzapine in meta-analyses in terms of weight gain/metabolic syndrome. Olanzapine is one of the worst weight gain/metabolic offenders. The thing that tends in my experience to lead to discontinuation for seroquel is the sedation and orthostatic hypotension sometimes. Just for an example:
Comparative effects of 18 antipsychotics on metabolic function in patients with schizophrenia, predictors of metabolic dysregulation, and association with psychopathology: a systematic review and network meta-analysis
Marked differences exist between antipsychotics in terms of metabolic side-effects, with olanzapine and clozapine exhibiting the worst profiles and aripiprazole, brexpiprazole, cariprazine, lurasidone, and ziprasidone the most benign profiles. Increased baseline weight, male sex, and non-white...www.thelancet.com
That wasn't really the context of what I was discussing but I see why you were arguing for quetiapine being slightly better than olanzapine in terms of weight gain because I mentioned "long term."
It depends on what you're optimizing for. If people are super severely depressed and need a response then I agree you want something with robust proven effectiveness. But in terms of maintenance regimen for average outpatient with bipolar, especially if they do not have super severe episodes, I'm giving them a shot at lamotrigine, lurasidone, or lithium first. The effect size/quality of evidence may be weaker but the effect size doesn't matter if your patients stop taking the med because they're getting fat/feel super sedated all the time. (I'm not ignoring that the latter two still have some weight gain associated as well)
Latuda is also a tough medication for some people due to needing to take it with food. Hard to give a sedating med that needs 350 calories at dinner as some people zonk out after. If you need to split to BID dosing then you have AM sedation to deal with. Honestly real adherence for Geodon and Latuda is probably dramatically under 50%.
I just can't get over how many NPs are putting people on Zyprexa for "sleep". I mean its bad enough when they use Seroquel as first line for that, but I've been seeing all these patients on 2.5-5 mg Zyprexa for sleep per the patient, in many cases when they're already on another low to moderate dose SGA. I just don't get where they get these regimens from.
Or getting them off Zoloft 200 and Wellbutrin with a bipolar 2 diagnosis, whose also being prescribed adderall and Klonopin
BRB, patenting intranasal venlafaxine
In my limited experience no one with bipolar 1 , schizoaffective or schizophrenia stays stable for very long on Abilify. Seen much better outcomes with zyprexa, risperdal, clozaril. I know that's probably not everyone's experience. If anyone else has had this experience with Abilify I'd be interested to know.
Oooh and the akathisia with latuda. Every patient I've put on latuda gets akathisia
Subjectively, and I believe the data supports this, there is less akathesia in adolescents (and markedly more weight gain) with the atypical class. It clearly still happens and Abilify is very commonly used so its extremely important to pickup.
And then you take some time to explain the time requirements and ask the same question. They insist that they had mania that lasted two hours last night and again last week.
Same experience. The only people actually controlled on monotherapy I have had were on Maintena. Not even the handful I've had on Aristada have done particularly well on it alone.
