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nicolee

In need of medication suggestions

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I need a suggestion to replace Seroquel IR.  I've been on it since November, and since starting it, I consistently sleep 12+ hours a night, and more than that on weekends.  It's almost impossible to function during the day while I'm at work.  I'm seeing my pdoc on Thursday for a med change because this is unacceptable to me.  I do not have insurance, so I am looking for a medication that I can either get as a generic (with GoodRX) or through a medication assistance program (I make about $23K a year, no dependents).

In the past I have taken Geodon (won't do that again...withdrawals were HELL), Latuda, and Depakote (not an option due to severe tremors that affected job performance).  I currently take Topamax and Lamictal with the Seroquel.

I appreciate any suggestions given.  

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@nicolee

 

Abilify is generic. It doesn't sedate me. And I find it weight neutral. I don't know if that matters to you. It can be activating to some people. 

There is Seroquel XR if Seroquel works well for you. It is generic but might still be pricey. Not sure. But I felt much much less sedation on it versus the regular IR Seroquel. 

Risperdal is generic and cheap. It is a good med. It didn't sedate me and I didn't gain weight on it. Invega is also generic and is pretty much the same as risperdal but supposedly less side effects. Invega might be more expensive too. 

The new ones out there are Vraylar and rexulti for patient assistance. But rexulti is not approved for bipolar so I don't know if you'd be able to get it through their a assistance program. Vraylar is approved for bipolar though. I've never taken it but some people here do. Hopefully they will chime in. 

Zyprexa is cheap and generic. It is less sedating than Seroquel IME but weight gain can be a problem. But it works wonders for me. 

Then there are older typical antipsychotics. Like Haldol. But you might want to stick to one of the previously mentioned antipsychotics unless you've tried a lot to them. But some people do prefer the typical ones. I'm not trying to knock them at all. They have their use for sure. 

Edited by Wonderful.Cheese

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What symptoms are you looking to control?  Mood stabilization, mania prevention, psychosis prevention, etc.  or all of the above?  Also, beyond oversleeping, what side effects do you struggle with?

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Lithium's cheap as dirt and good for mood stabilization in both the depression and mania sides of the spectrum, or at least it has been for me and many here.  Requires periodic bloodwork because the difference between therapeutic and toxic is a little precarious, but it can be a good for many.

I second risperdal.  It was great before it gave me EPS symptoms and I'd still be on it but for that.  Also quite cheap. 

I also find zyprexa to be less sedating than seroquel. 

So I guess the short version is that I agree with WC, with the addition of lithium.

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Lithium is always worth a look I agree. I would also look at aripiprazole (generic abilify) I found on good Rx but it seems like it's very expensive for a generic 

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I'd try Risperdal over Lithium. Risperdal is not nearly as sedating as Seroquel and it doesn't tend to cause akathisia. Lithium, although a great antimanic, will cause kidney damage if you do not stay adequately hydrated. I took it for a few years until a secondary interaction with another med damaged my kidneys. Imo, it's a great med to stop mania but not the best for ongoing maintenance.

Edited by Stacia

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I have kidney disease, and kidney damage, and my nephrologist told me lithium was completely fine for me to use. My kidney values haven't changed at all, and I've been on it for 10 years. I think it is a good idea to speak to your doctor before you try lithium if you have kidney issues, but it shouldn't be taken off the table completely.

Oh, and my dad was a psychopharmacologist who did a lot of research on lithium. He thought it was safe for me to use, too.

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I would say lithium or Abilify. Ability ended up being my wonder drug, even though it heightened my mood for a few weeks.

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Yes pill (or liquid form). It helps BPs to not fall into depression and has anti-suicidal effects. No one is 100% how it works exactly, just that it's a great mood stabilizer. Not sure it's really meant for anxiety, although some get a little relief. Are you BP? 

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On 2/13/2018 at 12:01 PM, Wonderful.Cheese said:

Abilify is generic. It doesn't sedate me. And I find it weight neutral. I don't know if that matters to you. It can be activating to some people. 

There is Seroquel XR if Seroquel works well for you. It is generic but might still be pricey. Not sure. But I felt much much less sedation on it versus the regular IR Seroquel. 

Risperdal is generic and cheap. It is a good med. It didn't sedate me and I didn't gain weight on it. Invega is also generic and is pretty much the same as risperdal but supposedly less side effects. Invega might be more expensive too. 

The new ones out there are Vraylar and rexulti for patient assistance. But rexulti is not approved for bipolar so I don't know if you'd be able to get it through their a assistance program. Vraylar is approved for bipolar though. I've never taken it but some people here do. Hopefully they will chime in. 

Zyprexa is cheap and generic. It is less sedating than Seroquel IME but weight gain can be a problem. But it works wonders for me. 

Then there are older typical antipsychotics. Like Haldol. But you might want to stick to one of the previously mentioned antipsychotics unless you've tried a lot to them. But some people do prefer the typical ones. I'm not trying to knock them at all. They have their use for sure. 

@nicolee I would second most of these suggestions above. Particularly Seroquel XR. Many people find that the sedation on Seroquel isn't as bad with the XR.

Another thing to keep in mind while you're working with your pdoc to hunt for a new med is the categories that Dr. Stephen Stahl came up with to break down the atypical antipsychotic class into sub-groups (references to patents are for the oral forms only):

  • The "-pines"
    • asenapine (Saphris) (brand-only, exclusivity until 01/2020)
    • clozapine (Clozaril) (generic, all patents expired)
    • olanzapine (Zyprexa) (generic, all patents expired)
    • quetiapine (Seroquel) (generic for both IR and XR, all patents expired)
  • The "-dones"
    • iloperidone (Fanapt) (brand-only, exclusivity until 05/2019)
    • paliperidone (Invega) (generic, all patents expired)
    • risperidone (Risperdal) (generic, all patents expired)
    • lurasidone (Latuda) (brand-only, exclusivity until 07/2020)
    • ziprasidone (Geodon) (generic, still on patent until 05/2019)
  • Two "pips" and a "rip"
    • aripiprazole (Abilify) (generic, recently obtained an extension for treatment of pediatric Tourette's, patents don't expire until 03/2027)
    • brexpiprazole (Rexulti) (brand-only, exclusivity until 07/2020)
    • cariprazine (Vraylar) (brand-only, exclusivity until 11/2020)

These are all part of the atypical antipsychotic class, but these subgroups each have subtle differences in their pharmacology. So with these groups in mind, we can look at what you've taken already to get an idea of where to go next.

You've already tried Latuda and Geodon, both of which are "-dones" but could be further sub-classified into "-sidones" as they do work SLIGHTLY differently from the other "-dones". So you MIGHT respond to other APs in the "-dones" sub-group, but the odds aren't really in your favor so far. I've personally only taken from this group Latuda and Fanapt. My recommendation based on my experience, don't bother with Fanapt. The cardiac side effects are not worth it.

The fact that Seroquel has worked well for you aside from the sedation would indicate to me that you might respond will to other "-pines". I personally didn't find the sedation from Zyprexa to be bothersome during the day, but it did cause quite a bit of weight gain, and it increased my lipids and glucose a bit even though I was only taking 5mg. That being said if you didn't gain much weight on Seroquel, there's a chance, albeit a slim one, that you might not gain weight on Zyprexa or you'll gain very little. So that's worth a shot.

Keeping in mind cost as well is why I put what is generic and still on patent. It's important to understand that when a pharmaceutical company gets a patent for a medication, they get exclusivity to market that new medication. However, the exclusivity period isn't as long as the patent period. Pharmaceutical companies can extend exclusivity by getting additional indications or providing the FDA with studies showing it can be used in additional populations. So they wait until the exclusivity gets closer, and then they submit trial data to the FDA to have another indication added and then their exclusivity gets extended. If they can't get any more indications, then they do studies to see if the medications work in pediatric patients to get a 6-month "pediatric extension" on their exclusivity. Abilify is a good example of a medication that came out in 2002 for schizophrenia and then bipolar mania in adults, but they've since added MDD add-on, Tourette's, and irritability associated with autism. So while Abilify would have been generic by 2010, they were able to draw that out until 2016 when a generic finally came out.

Keeping this in mind, you will see in the list above that for ziprasidone and aripiprazole, while they are available as generics, they are still on patent. So for aripiprazole, all the generic pharma companies have to pay royalties to Otsuka, thus driving up the cost of the medication. In short, a generic with no active patents will almost invariably be cheaper than a generic that is still on patent. A 90-day of my generic Depakote ER for example costs around $200 (for like 180x generic 500mg ER tablets) because AbbVie still has a patent on it. When that patent goes bye-bye, prices start to plummet.

So in regards to cost, either generics with no patents, or brand-only medications with patient assistance are going to be the way to go to keep your costs down.

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56 minutes ago, browri said:

A 90-day of my generic Depakote ER for example costs around $200 (for like 180x generic 500mg ER tablets)

@nicolee lol I stand corrected, 180 generic Depakote ER tablets (90-day for me) in total was $564. I paid $30. By contrast my famotidine prescription (generic Pepcid) costs $8.05 in total and I pay all of it because I don't even reach the $10 copay for a generic 30-day. And at that rate I wouldn't hit the $30/90-day copay either.

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3 hours ago, Wonderful.Cheese said:

@browri

I know your post wasn't meant for me, but thank you for the incredible information! I understand some new things now! Very interesting.

From,

a definite "-pines" girl ;)

 

I can even explain those categories a bit further. Atypical antipsychotics as a class are separate from typical antipsychotics because they have potent 5HT2A antagonism in addition to their activity at D2/D3 receptors. Those subgroups are divided that way based on the potency and ratio of serotonin activity to dopamine activity:

  • "-pines" are most potent at 5HT2A relative to D2. Additionally, most of the other serotonin receptors they block, they block more potently than dopamine receptors.
  • "-dones" still have 5HT2A antagonism that is more potent than D2 antagonism but few other serotonergic activities that are more potent than D2 antagonism. The only exception in this category is Latuda which is actually stronger at D2 than 5HT2A.
  • "Two pips and a rip" are preferential to dopamine modulation (not antagonism as these are all partial agonists) over 5HT2A but they may still have considerable 5HT2A activity. E.g. brexpiprazole has an affinity for D2 of 0.3nM and 5HT2A is 0.47nM making brexpiprazole the most "balanced" in this sub-group but still preferential to dopamine.
Edited by browri
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I take Abilify but have no insurance - and it is $300 at Walmart. Yikes. Sucks. 

Everything else I have taken though, either had crazy side effects or did not help so I stick with the Abilify. 

On ‎2‎/‎15‎/‎2018 at 1:28 PM, crtclms said:

I have kidney disease, and kidney damage, and my nephrologist told me lithium was completely fine for me to use. My kidney values haven't changed at all, and I've been on it for 10 years. I think it is a good idea to speak to your doctor before you try lithium if you have kidney issues, but it shouldn't be taken off the table completely.

Oh, and my dad was a psychopharmacologist who did a lot of research on lithium. He thought it was safe for me to use, too.

Off topic, sorry, but how do you know if lithium is causing kidney damage, do you know? I know I don't drink enough water maybe 6-8 on a daily basis. So they are probably shriveled up like little kidney beans.

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