Friday, 17 September 2010

Aripiprazole

Aripiprazole (trade name abilify) is an antipsychotic drug, licensed to market itself as indicated in the treatment of schizophrenia, mania and the control of agitation and disturbed behaviour in schizophrenia.

The BNF shows that a month's supply of aripiprazole 30mg has a reference cost of £191.47

Now, a drug cost of £2297.64 a year isn't actually that huge. Compare it to the cost of an admission to hospital and it's clear that keeping someone with manic/schizophrenia well for that amount is great for the patient and great for the NHS. Sure, there're medical costs of assessment and prescribing, pharmacist costs in dispensing, but actually it's still much better for the patient not to relapse and much more cost effective to spend staff/drug costs on this, than have an admission to hospital.

Haloperidol also is licenced for schizophrenia and mania. Top dose haloperidol is also 30mg a day (although I can't recall prescribing an older adult even 1/4 of that dose) at a reference cost of £52.28 a month and haloperidol is, usually, a drug causing a lot more side effects.

Olanzapine, in the treatment of schizophrenia and mania, has a top dose of 20mg a day, at a base cost of £158.90 a month.

I am happy to prescribe olanzapine. It seems well tolerated. It seems to work well. Aripiprazole is a newer and more expensive drug. It's a topic of conversation. It was discussed with Consultant Psychiatrists across 4 mental health hospitals. Working age and old age pschiatrists curiously formed the same view, with nobody seeming to think that aripiprazole seemed to work as well as other drugs. Some vociferously argued it didn't work at all.

Spending a few thousand a year on a drug that works and prevents admission both improves my patient's life and saves the NHS money.

Prescribing a drug that's of dubious effectiveness, hmmm.

Has anyone had decent results from this drug? I've yet to hear of it . . .

11 comments:

LittleFeet said...

It would seem that 15mg works for me. I no longer think I have a worm inside me that's making my brain go mouldy. Nor do I believe an eating disorder research team to be entering my house at night. My dead uncle doesn't talk to me anymore though I do still hear other voices. If pushed, I'd most likely suppose that my other voices are alters but that's a whole different matter entirely.

I tolerate Aripiprazole well. I've not gained 3 stone nor do I spend 22 out of 24 hours asleep like when I took Quetiapine. Aripiprazole doesn't make me want to taking a carving knife to my breasts like Risperidone did when I started to painfully lactate.

However, I would question the nature of my supposed psychosis. My consultant said "he doesn't buy it [my psychosis]" and I'm more of the opinion that supportive friends and family helped put an end to what I think is a recent episode of dissociatve psychosis.

Ceri said...

Yes, aripiprazole works FANTASTICALLY for my schizoaffective disorder.

Helps with the psychosis & paranoia - though I also do a lot of CBT to cope with that, so not entirely squashing it was acceptable.

Aripiprazole's also been the only thing besides marathon running to touch my recurrent depression. I went from mostly housebound with negative symptoms just sat on the sofa or crying from hallucinations, to happily running the Pembrokeshire Coast Path solo on aripiprazole (not manic, I just do that sort of thing).

Unfortunately I had to stop taking aripiprazole due to a very unusual reaction - my hair was falling out in handfuls.
Other than that, the only adverse effect was lowering my blood pressure to the point where it was hard to stand up mornings in the summer heat (I have background v low blood pressure anyway), and a smidgen of fidgety akasthasia to start with.

Tried olanzapine before which made me unacceptably groggy for daily use, loads of SSRIs were like taking Smarties + nausea & panic, mirtazapine made me too groggy to stand up, recently started venlafaxine (nausea, panic, sweating), and about to start quetiapine alongside.

If I could keep taking aripiprazole I absolutely would, it made me feel the best I ever have. Alas nothing else seems to have a similar pharmacological mechanism.

pj said...

Of the schizophrenic patients I've seen transfered onto aripiprazole results have always been pretty poor, switching inevitably leads to increased psychotic symptomatology - it is something I've often remarked upon with colleagues.

Some patients do, however, seem to tolerate it better than other antipsychotics, and often ask for a trial, although I can't help wondering whether we should just decrease the dose of something else and save all that money.

Zarathustra said...

I've seen it work well for some people (and badly for others). In some cases for those it seemed to work it may not have been a true psychosis - which made Littlefeet's comments particularly interesting to me.

I've seen others where the response was initially poor, but if the medication was persisted with, they then seemed to improve. It may be that it just has a longer onset of action than it's supposed to.

Alie said...

I don't know if you're going to be prescribing it for depression, but it's worked fantastically as an adjunct for me for my triple depression (MDD, dysthymia, RBD, Seasonal AD) at 5mg.

jessa said...

I've taken it as an adjunct to anti-depressants for depression and anxiety. (Which now, more than a year later, is exactly what the commercials want me to use it for. I live in the US.) It didn't make me sleep every moment I possibly could, like risperdone, but it did make me gain weight. That weight gain part is why I refuse to take it again. It was just some very unfortunate timing for me, but I had just finally decided to eat my full meal plan after many assurances from my dietitian that eating the full meal plan would not make me gain weight. I did gain weight, but it was the aripiprazole, not the meal plan. Ick.

Alie said...

Just FYI it did not make me gain weight.

Ceri said...

Small weight loss for me, and it helped a LOT with the negative symptoms / depression / lack of attention to self-care. Even started to think about going back to work on it. Desperately wish I could keep taking it.

Zarathustra, interesting point about the long-term use. I can take olanzapine PRN on bad days, and it knocks the psychosis out the same day (also knocks me out, which is why I don't like it).

Aripiprazole I can't do that with, short-term it does nothing, but after a few weeks, maybe a month, it reduced paranoia, voices, and other psychotic symptoms - as well as knocking out distressing obsessive thoughts, flashbacks and anxiety brilliantly.
This does make me wonder if it's maybe particularly well suited to hallucinations associated with trauma rather than 'straight' psychosis?

Seriously though, aripiprazole was my wonder drug after ten years of going through loads. If I can work out the hair loss isn't associated with anything too scary, I might just go back to it and go bald :(

banshee said...

Interesting comments.

As a practising pharmacist in the field of mental health I can anecdotally describe that it's often prescribed where other medicines are ineffective and therefore has the ante raised against it being beneficial and that there is a lack of appreciation that as a partial dopamine agonist and a medicine with a long half life rapid dose escalation is counter productive.

It's place in therapy has yet to be established but given the side effect profile of medicines like olanzapine it may be helpful in areas like first episode schizophrenia. Fhe FDA turned down an application in depressive disorders and it probably sits in a distinct therapeutic area to other antipsychotics.

The Shrink said...

LittleFeet, Ceri, Alie, Jessa, it's good to hear that it genuinely is helpful to you - vanishingly few psychiatrists seem to be hearing that so it's healthy to have a balanced view that it can be very useful indeed.

Zarathustra, Banshee, it does have a different mode of action (as a partial agonist), rather than blockade, so I'd believe the outcomes were realised over time, rather than the more immediate/dramatic effects of dopamine blockade that haloperidol etc affords.

PJ, a fair point that patients experiencing aripiprazole usually aren't receiving it first line, so outcomes inevitably will be less favourable than drugs we use more often, with better outcomes, true.

amazonmom said...

my friends that have bipolar II disorder swear by aripiprazole. Nice stable mood, not sedated, no TD or extrapyramidal symptoms so far. Great compliance because the med doesn't cause them bothersome problems.

If I offered haloperidol to these people they would laugh me out of the room! I know it's cheap but asking someone to take this for the next several decades with that huge side effect burden sounds ridiculous to me.