The Latest and Greatest on Psychotropic Medications: The Bottom Line

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The Latest and Greatest on Psychotropic
MedicationsThe Bottom Line

• Ann M. Hamer, PharmD
• Clinical Psychopharmacology Consultant
• OSU College of Pharmacy
• Oregon Office of Medical Assistance Programs

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• Separating industry fact from fiction
• Cost-effective utilization of psychotropic
  medications

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Industry Rumors
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Rumor 1

• Seroquel causes cataracts

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Background

• Pre-marketing Linked to cataract formation in
  beagles

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The Facts

• Doses were in excess of 4 times the recommended
  adult dose
• There are no known case reports of
  Seroquel-induced cataracts in humans

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Rumor 2

• Lexapro is better than Celexa

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Background

• Lexapro, or escitalopram, is the s-enantiomer of
  citalopram
• It is more potent
• It is less expensive

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The Facts Potency

• Lexapro is more potent than Celexa, but what does
  that mean clinically?
• 10mg Lexapro 20mg Celexa
• 10mg Lexapro 40mg Celexa
• 10mg Lexapro 20mg Lexapro
• 20mg Celexa 40mg Celexa

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The Facts Cost

• 30 days Lexapro 10mg 61.99
• 30 days Celexa 20mg 66.99
• Celexa patent expiration early 2004
• Generics available as early as January

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Rumor 3

• Paxil CR is better tolerated than the original
  Paxil

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Background

• Due to its matrix formulation, Paxil CR is
  released more slowly into the body than the
  immediate release formulation

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The Facts

• Time to maximum drug concentration is extended by
  8 minutes to 4.8 hours.
• Paxil t1/2 21 hours
• Paxil CR t1/2 15-20 hours
• Equivalent time to reach steady state

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Improved tolerability?

• Paxil CR
• Headache 27
• Nausea 22
• Diarrhea 18
• Insomnia 17
• Abnormal Ejaculation 26
• Female Genital Disorder 10

• Paxil
• Headache 18
• Nausea 26
• Diarrhea 12
• Insomnia 13
• Abnormal Ejaculation 13
• Female Genital Disorder 2

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Difference in cost?

• 30 days Paxil 20mg 77.99
• 30 days Paxil CR 25mg 79.99
• 30 days Paxil 40mg ½ tab QD 42.49
• Cannot split a controlled release matrix

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Rumor 4

• Prozac Weekly offers a dosing advantage over the
  original product

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Background

• Prozac Weekly capsules contain enteric-coated
  pellets of fluoxetine hydrochloride equivalent to
  90mg of fluoxetine

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The Facts Pharmacokinetics

• The elimination t1/2 of fluoxetine is 4 to 6 days
  after chronic administration
• Norfluoxetine, an active metabolite, further
  extends the duration of action with a 4 to 16 day
  elimination t1/2
• The original product can be used in a similar
  fashion

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The Facts Cost

• 28 days Prozac Weekly
  (4 capsules) 79.99
• 30 days generic fluoxetine 20mg 33.99
• Some health plans pay as little as 3 per month
  for generic fluoxetine

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Rumor 5

• Weight gain associated with Zyprexa is minimal
  and controllable

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Background

• Some people who have taken ZYPREXA have reported
  weight gain. If you are concerned about the risk
  of gaining weight, talk to your doctor about
  changes you can make in your activities or eating
  habits to help manage your weight.

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The Facts

• On average, patients taking Zyprexa will gain
  24-25 pounds in the first year of therapy
• Mechanism unknown
• Not purely related to increase in appetite
• Also linked to hypercholesterolemia and glucose
  dysregulation
• Case reports of DKA, diabetic coma and death

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The Facts
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Cost-Effective Utilization of Psychotropic
Medications
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Paxil 20mg QD

• 77.99

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Celexa 20mg QD

• 66.99

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Zoloft 50mg QD

• 69.99

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Effexor XR 75mg QD

• 76.99

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Seroquel 100mg BID

• 156.00

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Risperdal 2mg BID

• 273.98

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Geodon 40mg BID

• 229.99

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Abilify 10mg QD

• 265.99

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Zyprexa 10mg QD

• 262.99

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Zyprexa 20mg QD

• 509.99

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Instead . . .

• 12 oz New York steak
• 1 bottle imported wine
• 1 qt Ben Jerrys

501.30
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From SYBASE Drug2001, Drug2002 and DHS Finance
Policy Analysis Rate Setting report Service
dates 7/1/01-12/31/02 Total Funds before rebate,
includs FCHP drugs, includes all eligibility
groups
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10 MH Drugs Account for 38 of Gross OMAP FFS
Drug Cost

• Drug Annualized Percent of
• Gross Spend Total Spend
• ZYPREXA 23,283,500 8.65
• RISPERDAL 15,864,500 5.89
• NEURONTIN 12,314,500 4.58
• SEROQUEL 9,446,000 3.51
• PAXIL 8,990,500 3.34
• ZOLOFT 8,805,000 3.27
• EFFEXOR XR 6,709,000 2.49
• DEPAKOTE 6,523,000 2.42
• WELLBUTRIN SR 6,140,000 2.28
• CELEXA 5,314,000 1.97
• Total 103,389,000
  38.42

From SYBASE Drug2003, based on service dates
1/1/03-4/17/03, Total Funds before rebate,
excludes FCHP drugs
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Paxil 20mg QD

• 77.99

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Paxil 40mg ½ tab QD

• 77.99?42.49

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Fluoxetine 20mg QD

• 77.99?9.60

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Paxil 20mg alternatives

• Paxil ½ 40mg
• Saves 35.50 per Rx
• Saves 426.00 per pt per year
• Saves 42,600 per 100 pts per year

• Fluoxetine 20mg
• Saves 68.39 per Rx
• Saves 821.00 per pt per year
• Saves 82,100 per 100 pts per year

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Celexa 20mg QD

• 66.99

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Celexa 40mg ½ tab QD

• 66.99?34.99

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Fluoxetine 20mg QD

• 66.99?9.60

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Celexa 20mg alternatives

• Celexa ½ 40mg
• Saves 32.00 per Rx
• Saves 384.00 per pt per year
• Saves 38,400 per 100 pts per year

• Fluoxetine 20mg
• Saves 57.39 per Rx
• Saves 689.00 per pt per year
• Saves 68,900 per 100 pts per year

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Zoloft 50mg QD

• 69.99

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Zoloft 100mg ½ tab QD

• 69.99?35.49

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Fluoxetine 20mg QD

• 69.99?9.60

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Zoloft 50mg alternatives

• Zoloft ½ 100mg
• Saves 34.50 per Rx
• Saves 414.00 per pt per year
• Saves 41,400 per 100 pts per year

• Fluoxetine 20mg
• Saves 60.39 per Rx
• Saves 725.00 per pt per year
• Saves 72,500 per 100 pts per year

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Effexor XR 75mg BID

• 153.98

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Effexor XR 150mg QD

• 153.98?83.99

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Effexor XR 150mg QD

• 153.98?83.99 70 savings per month

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Risperdal 2mg BID

• 273.98

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Risperdal 4mg QD

• 273.98?215.00

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Risperdal 4mg QD

• 273.98?215.00 60 savings per month

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Geodon 40mg BID

• 229.99

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Geodon 60mg BID

• 229.99?229.99 0 savings per month

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Zyprexa 10mg BID

• 539.99

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Zyprexa 20mg QD

• 539.99?509.99 20 savings per month

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• Costs Associated with Commonly Prescribed
  Psychotropic Medications
• Drug Cost/Month Cost/Year
• Antidepressants
• Fluoxetine 20mg QD 9.60 115
• Lexapro 10mg QD 61.99 744
• Celexa 20mg QD 66.99 804
• Zoloft 50mg QD 69.99 840
• Zoloft 100mg QD 70.99 852
• Paxil 20mg QD 77.99 936
• Paxil CR 25mg QD 79.99 960
• Effexor XR 75mg QD 76.99 924
• Effexor XR 150mg QD 83.99 1008
• Antipsychotics
• Risperdal 4mg QD 215.00 2580
• Geodon 40mg BID 229.99 2760
• Seroquel 100mg BID 156.00 1872
• Seroquel 200mg BID 292.98 3516
• Abilify 10mg QD 265.99 3192

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• Cost-Effective Alternatives
• Alternative Savings per Rx Savings per patient
  per year Savings per 100 patients per year
• Paxil 20mg QD
• Paxil ½ 40mg QD 35.50 426 42,600
• Fluoxetine 20mg QD 68.39 821 82,100
• Paxil CR 25mg QD
• Paxil ½ 40mg QD 37.50 450 45,000
• Fluoxetine 20mg QD 70.39 845 84,500
• Celexa 20mg QD
• Celexa ½ 40mg QD 32.00 384 38,400
• Fluoxetine 20mg QD 57.39 689 68,900
• Lexapro 10mg QD
• Celexa ½ 40mg QD 27.00 324 32,400
• Fluoxetine 20mg QD 52.59 629 62,900
• Zoloft 50mg QD
• Zoloft ½ 100mg QD 34.50 414 41,400
• Fluoxetine 20mg QD 60.39 725 72,500
• Prozac 20mg QD