Wednesday, September 07, 2011

The Carlat Blog just got WAY more interesting

A reader writes,

Dear Doctor: Now that CGS (Complicated Grief Syndrome) is the hot new psychosis, are there any neat drugs in the pipeline with cool side effects?

Inquiring junkies want to know.

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Dear Reader,

Thanks for your missive. The sad fact is that the psychiatric drug pipeline is flowing at a trickle these days. There's not much that's novel; most new drugs are either tweaks on existing drugs or "me-too" drugs in the same family as existing drugs. As one commenter in one of my favorite blogs recently observed, most new psych meds introduced since 1987 have been a clone of either Prozac (SSRI class antidepressant) or Clozaril ("atypical" antipsychotic).

I've found the recent entries on said blog very interesting. Not sure if you guys will enjoy this discussion as much as I have, but for the curious, here's the back story.

Blog author Daniel Carlat (mentioned here previously) is a psychiatrist in the Boston area who has taken up the noble cause of getting the pharmaceutical industry out of the continuing medical education (CME) business. Up until now, there's been a lot of CME programs that were sponsored by "Big Pharma", to use the somewhat pejorative term. Such programs, unsurprisingly, cast the product(s) of the sponsor in a positive light, making it hard to tell how much of the content was objective and how much was "spin" or bias.

Carlat is not alone in his quest. A lot of medical schools have done away with the old practice of industry-sponsored Grand Rounds, drug lunches, drug dinners, and, in some cases, visits from drug reps entirely. The AMA is starting to voice its concerns as well.

Carlat is, however, one of the more vocal critics of Big Pharma, leading to
this recent response by Stephen Stahl. Dr. Stahl is a psychiatrist and educator. He is on the faculty at UC San Diego and has his own Neuroscience Education Institute, through which he offers CME at symposia around the country. He is also a paid consultant/speaker/researcher for just about every pharmaceutical company - over a dozen of them. So if anybody is qualified to be the opposition in this argument, it's him.

So Dr. Stahl has taken up the fight against the influence of Dr. Carlat and others, calling him a "Pharma-scold" and alleging that, because of people like him, the pipelines are drying up. It's quite a leap, to me, to draw that conclusion, and, I must say, Dr. Stahl's response seemed quite over-the-top, as did the later followup by his minion associate, Debbi Ann Morrissette, PhD.

My take on the whole thing is that Carlat has a genuine concern. When I was in medical school and residency, one of the popular games at Grand Rounds was "Guess The Sponsor". It was an easy game, usually over within five minutes. That was about how long it took to introduce the subject matter and begin talking about the studies that showed how drug X was a good choice for the disease under discussion. Bipolar disorder with rapid cycling? Depakote is good for that. Hey, the guys in the back row are wearing Abbott Labs name tags. I win a free breakfast!

The other side of the coin is that, as far I can tell via the literature and my own clinical experience, Depakote is really the best drug for that condition, so "Big Pharma" has gotten out a message that will help me help patients. And Abbott did disclose that they were the sponsors of the Grand Rounds. And, well, this is America, where capitalism encourages the companies to promote their products, generate sales, and generate profit. The hope is that the profit is married to real benefit for patients, not just the shareholders and those in the company who get bonuses for sales.

Monday, July 18, 2011

New antidepressant - ViiBRYD - my 2¢

(Yeah, it's been a while. This was originally posted last week on the Axiom Message Boards)

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So there's a new antidepressant out, which is always kind of exciting. The antidepressant pipeline has been kind of dry for the last decade.

However, my initial impression after a bit of research is that, as is often the case, this new medicine will be an expensive way to get approximately the same effect that you can get with currently available generic medications.

The brand name of the new medication is ViiBRYD. Aren't the cutesy double lower case "i"s about enough to make you barf? The scientific/generic name is vilazodone, which at once made me think of trazodone (Desyrel) and nefazodone (Serzone), antidepessants from the 1980s. Indeed, vilazodone is a piperazine-class compound, just like trazodone, nefazodone, and a whole host of other medications.

The drug rep proposed that ViiBRYD works like a combination of Lexapro and Abilify, because it inhibits serotonin intake, like Lexapro and the other SSRIs (selective serotonin reuptake inhibitors) and is a partial agonist of the serotonin 1-A receptor (like Abilify). Thus, a patient can avoid the currently in vogue regimen of adding an atypical antipsychotic (Abilify, Seroquel) to his antidepressant, getting similar effects in one pill instead of two. Fewer copays, etc.

Wow! Sounds good! Those are some powerful meds you're emulating, alright! Sign me up and let me hand out these samples to all of my depressed patients!

Wait. What the drug rep didn't mention is that Abilify is actually much more than just a serotonin 1-A partial agonist. Its activity there doesn't even account for the majority of its therapeutic effect, which is from its effect on dopamine, where it is also a partial agonist. All in all, Abilify is active in almost a dozen ways - I call it my Swiss Army knife: good for almost anything.

A more accurate analogy would be to say that ViiBRYD is like a combination of Lexapro (or your SSRI of choice) and buspirone (BuSpar). Buspirone is a 1980s era molecule which had modest success treating generalized anxiety before going generic in 2001. About all it does chemically is through that serotonin 1-A receptor, so it was billed as having virtually no side effects. Of course, many patients also said it had virtually no good effects, either, but often they had seen the big guns of benzodiazepines (Xanax, Valium, Klonopin, etc) and, by that point, addressing their anxiety with buspirone was like addressing a bear with a slingshot. Now, for benzodiazepine-naive patients, buspirone was pretty decent. But I digress.

Anyway, on the $4 list at WalMart, Target, and several other pharmacies, one can find not only buspirone but several decent SSRIs such as fluoxetine (Prozac), paroxetine (Paxil), and citalopram (Celexa). I like citalopram due to its good overall tolerability. It was the precursor to Lexapro, anyway, with the same active ingredient; Forest Pharmaceuticals just played some isomer games to create Lexapro. So citalopram + buspirone = SSRI effect plus serotonin 1-A effect for $8. I don't have cost info for ViiBRYD, but most branded antidepressants are ~$200 a month. Even with insurance, you'll probably have a tier 3 copay, if it is even covered in the first place.

So I don't think I'll be writing a lot of ViiBRYD. But it was nice of them to remind me of some of the pharmacologic principles at work so that I could save my patients, and the health care system, some money.