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.

5 comments:

Jennifer said...

I was told 155.25 for a month supply today.

Naef Basile said...

Hi Doc-
I must take issue with the assertion that the neurological effects of ViiBRYD could be more cheaply simulated by purchasing generic Celexa plus generic Buspar.
During the past twenty years I have tried every SSRI and SNRI, and approximately 60% of the old tricyclics. EVERY antidepressant exerts it's own unique effects upon the synaptic receptors. The problem is that we, the patients, are the ones who have to discover (and endure) all of these quirks that each unique molecule causes in how it bonds to receptors. I suggest that in order to acquire a truly authoritative awareness on the subject, you first try a Celexa-Buspar combo, and then 48 hours later, try the ViiBRYD. Unless you were to do this, there is no way to know if the seritonin reuptake blocking effect of ViiBRYD feels even remotely like the effect of Celexa. I plan to try ViiBRYD very soon, but even without having experienced it yet, I'd bet a hundred bucks that the vast majority of patients would not say that it feels anything like Celexa. Even LEXAPRO does not feel like Celexa, and it is composed of the most active part of the Celexa molecule!!!
Lastly, think about this: Forest Laboratories' patent on Celexa and Lexapro have expired, and Forest has recently bought the manufacturer of ViiBRYD. Could Forest Labs experience success by marketing the expensive new ViiBRYD if ViiBRYD made people feel like they were taking the low-priced generic forms of Celexa or Lexapro?! To say yes to that question would defy all logic, as well as scoff at the exact reason why different pharmaceutical companies experience success with new "me too" SSRIs and SNRIs. Each "me too" has it's own neuropharmacological profile, consisting of it's particular action on the reuptake receptors. Subjectively, the patient easily senses that each of the different antidepressants brings it's own unique set of positive and distressing feelings; (from what happens when it's unique molecule bonds to a reuptake receptor). Why else would one of your patients tell you that she likes Paxil better than Prozac, or Celexa more than Desyrel?
Naef Basile
Mount Vernon,NY

Unknown said...

I just looked up the price at Wallmart $136.11 30 day supply.
For women I believe you must read the side effects of this drug. I at age 50 was lactating a small amount and my Dr. at the time said my protien was high a MRI with and without contrast was done on my pituitary gland and show it had grown. I was put on Cabergoline 4 pills 1/2 weakly.. @ 100.00 a month.. I went off them by choice..Now I have CML and that drugh is $4,505.32.
Gleevic will be going generic soon I hear.. Lucky to be on SS disability Medicare at age 58..

Unknown said...

Celexa 40 mg. I have been on for 10 years.

Anonymous said...

I am one of those people that over the last 25 years has tried just about everything on the market. For many many years I had good luck with Effexor, but the last year or so didn't feel it was working well. My doc put me on Lexapro, yuck! My sister recently started taking Viibryd and likes it! My group health insurance will not cover it, what a crock! If I can get it for 155.00 a month I am desperate as I am feeling REALLY depressed ( in a black hole) recently! I went back on Effexor had a BAD reaction to Celexa! Ugh! I am feeling very desperate for HELP, I don't even have a doc now as she just moved out of state After treating me for 25 years! Many doctors around here won't treat with anti-depressants or anti- anxiety meds! CRAZY! Any suggestions for a good anti depressant/anxiety med would be appreciated! PS! Tried buspar many years ago had horrid horrid nightmares!