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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 67 to 91 of 8406. Go back in thread:
Posted by .tabitha. on August 17, 2002, at 15:35:49
In reply to Re: sexual s/e Phil » pharmrep, posted by Phil on August 16, 2002, at 12:36:50
Posted by dr. dave on August 19, 2002, at 4:52:24
In reply to Anyone switched to Lexapro? « ggrrl, posted by Dr. Bob on June 11, 2002, at 7:52:48
The Danish Institute for Rational Pharmacotherapy has reviewed all of the available data comparing Lexapro and Celexa and has concluded there is no convincing evidence for any difference in tolerability, efficacy, or anything else. This is the only other independent review of the data apart from Micromedex I am aware of. It is only those linked with the manufacturers of Lexapro that are talking it up, and the only two independent reviews come to the same conclusion - there is no real difference. The story is on the Reuters news website.
Posted by Ritch on August 19, 2002, at 9:45:37
In reply to Re: Lexapro is no different from Celexa, posted by dr. dave on August 19, 2002, at 4:52:24
> The Danish Institute for Rational Pharmacotherapy has reviewed all of the available data comparing Lexapro and Celexa and has concluded there is no convincing evidence for any difference in tolerability, efficacy, or anything else. This is the only other independent review of the data apart from Micromedex I am aware of. It is only those linked with the manufacturers of Lexapro that are talking it up, and the only two independent reviews come to the same conclusion - there is no real difference. The story is on the Reuters news website.
>
>Hi Dave,
If that is the case, then the "s" isomer would truly be no more effective than the "r" isomer (or at least not more effective enough to be statistically significant). Also, given that logic, then the 10mg and 20mg tabs of Lexapro would simply be lower dose versions of Celexa. The first time I tried Celexa I took 10mg and then needed to increase it to 20mg, but it didn't seem to help much more (at that time). So, you are in essence saying that they are giving us lower doses and nobody will know any difference because the dose/response curve of Celexa (and other SSRI's) is so flat??
Mitch
Posted by Anyuser on August 19, 2002, at 11:12:18
In reply to Re: Lexapro is no different from Celexa, posted by dr. dave on August 19, 2002, at 4:52:24
Let's say you're a practicing physician (no offense intended, this is after all the internet). A threshold question is whether you are dubious of antidepressant drugs in general, never prescribe 'em, and instead prefer talk therapy. Let's say you do indeed prescribe antidepressants in your practice. The next question is whether you prescribe Celexa. Let's say you do indeed prescribe Celexa, and find through experience that it works for some but not all of your patients.
Now here comes a Forrest Labs marketing rep who says that Lexapro is better than Celexa. Everybody and their dog knows that the data that comes out of any drug manufacturer is of limited value, subject to bias, etc. Even so, maybe Lexapro is a little bit better than Celexa. Who knows, maybe it's a lot better. Then again, maybe Lexapro's not better at all, but identical to Celexa. There would be nothing remarkable about a new SSRI that works no better than all the other SSRIs. That would be old news. Then again, who knows why Zoloft is more effective that Paxil for some, and the reverse is true for others?
I'm pretty sure my pdoc doesn't consult the Danish Institute for Rational Pharmacotherapy (although I am generally very nervous about where he gets his nutty ideas, but let's put that aside). The institute, according to its website, "has the task of ensuring the population the most rational utilisation of the range of medicinal products available on the basis of both effectual and financial points of view." The only time a financial point of view enters into my relationship with my pdoc is if there is an issue as to whether my insurance will cover a medicine that he prescribes. Fortunately for me, that is never an issue. Let's say insurance issues don't enter into your decisions as to what to prescribe (but let us know if that is a mistaken assumption, let us know if you work for an HMO controlled by an insurance company).
Now let's say you have a patient whom you think might benefit from Celexa. Why wouldn't you write the prescription for Lexapro instead?
Posted by shar on August 19, 2002, at 12:42:43
In reply to How do you act on that information? » dr. dave, posted by Anyuser on August 19, 2002, at 11:12:18
>The institute, according to its website, "has the task of....on the basis of both effectual and financial points of view."
>The only time a financial point of view enters into my relationship with my pdoc is if there is an issue as to whether my insurance will cover a medicine that he prescribes. Fortunately for me, that is never an issue.
I don't know about others here, but the financial point of view for me is what it's all about. Without health insurance, and being unemployed, (does that spell Loser?), decisions about my meds are mostly narrowed down to what I can afford.
For example, I recently got off Effexor, because it's so expensive, but not before I had cut the dose in half to make the script last twice as long. Tried generic nortrip and was sick as a dog from it, so let that go--but it was very affordable.
So, any institute that is looking at financial concerns is tops in my book.
Shar
Posted by Anyuser on August 19, 2002, at 13:46:42
In reply to Tangent on Costs, posted by shar on August 19, 2002, at 12:42:43
Yours is a valid and important point. Cheaper generic citalopram is on its way, whether Lexapro is better or not, and that's a good thing.
You are not a loser, and your parenthetical question is what my pdoc calls "negative cognition." Chin up!
Posted by johnj on August 19, 2002, at 16:04:26
In reply to Re: Lexapro is no different from Celexa, posted by dr. dave on August 19, 2002, at 4:52:24
So the University of Nebraska's research was bogus? Whose research do we believe?
Posted by Maximus on August 19, 2002, at 17:26:48
In reply to Re: Lexapro is no different from Celexa, posted by dr. dave on August 19, 2002, at 4:52:24
Posted by Patson on August 19, 2002, at 23:10:54
In reply to Re: Lexapro is no different from Celexa, posted by dr. dave on August 19, 2002, at 4:52:24
I might guess that you sound an awful lot like a friend of mine who is a glaxo rep.... He's been telling me the same thing....
> The Danish Institute for Rational Pharmacotherapy has reviewed all of the available data comparing Lexapro and Celexa and has concluded there is no convincing evidence for any difference in tolerability, efficacy, or anything else. This is the only other independent review of the data apart from Micromedex I am aware of. It is only those linked with the manufacturers of Lexapro that are talking it up, and the only two independent reviews come to the same conclusion - there is no real difference. The story is on the Reuters news website.
>
>
Posted by Patson on August 19, 2002, at 23:18:08
In reply to Re: Lexapro side-effects » dr. dave, posted by Ritch on June 19, 2002, at 9:11:56
> > Just for accuracy of information... Celexa's patent in the US won't expire until 2003. There is also a six month exclusivity extension due to clinical studies conducted in children. In addition, a generic citalopram would take about 18 months to get approval from the FDA. A generic equivalent for Celexa then wouldn't be available until sometime in 2005.
> > The research shows Lexapro has no significant benefit over Celexa in terms of side-effects. People taking Lexapro 20mg report side-effects at the same rate as those on Celexa 40mg (86%).
> >
> > In the same study more people stopped taking Lexapro 20mg because of side-effects than those taking Celexa 40mg (10.4% vs 8.8%), but this difference was not statistically significant.
> >
> > The reason for this is that Lexapro is to all intents and purposes the same thing as Celexa but re-branded and re-patented. There is no evidence of the R-citalopram component they have removed doing anything of significance pharmacologically. To understand this 'new' drug you have to understand that the patent on Celexa just ran out, but the manufacturers can effectively renew the patent by isolating the active component and re-branding it.
> >
> > See more at http://www.guardian.co.uk/Archive/Article/0,4273,4434943,00.html
> >
> > The critical comments in the article are mine.
>
>
> Hi,
>
> Thanks for the article. It wouldn't surprise me a whole lot if the only advantage it winds up having is less medicine for your liver to clear out! I have always wondered about the "mechanism" versus "medicine" distinction between antidepressants when it comes to how they work and side-effects. SSRI's all tend to cause many similar wanted and unwanted effects. If they isolated the *active* isomer, then they probably isolated something that is *more* likely to cause typical SSRI wanted and *unwanted* effeects. It will be interesting to see the comments made here when people start "reporting" in about it.
>
> Mitch
>
Posted by pharmrep on August 19, 2002, at 23:46:50
In reply to Re: Lexapro side-effects, posted by Patson on August 19, 2002, at 23:18:08
> > > Just for accuracy of information... Celexa's patent in the US won't expire until 2003. There is also a six month exclusivity extension due to clinical studies conducted in children. In addition, a generic citalopram would take about 18 months to get approval from the FDA. A generic equivalent for Celexa then wouldn't be available until sometime in 2005.
>
>
> > > The research shows Lexapro has no significant benefit over Celexa in terms of side-effects. People taking Lexapro 20mg report side-effects at the same rate as those on Celexa 40mg (86%).
> > >
> > > In the same study more people stopped taking Lexapro 20mg because of side-effects than those taking Celexa 40mg (10.4% vs 8.8%), but this difference was not statistically significant.
> > >
> > > The reason for this is that Lexapro is to all intents and purposes the same thing as Celexa but re-branded and re-patented. There is no evidence of the R-citalopram component they have removed doing anything of significance pharmacologically. To understand this 'new' drug you have to understand that the patent on Celexa just ran out, but the manufacturers can effectively renew the patent by isolating the active component and re-branding it.
> > >
> > > See more at http://www.guardian.co.uk/Archive/Article/0,4273,4434943,00.html
> > >
> > > The critical comments in the article are mine.
> >
> >
> > Hi,
> >
> > Thanks for the article. It wouldn't surprise me a whole lot if the only advantage it winds up having is less medicine for your liver to clear out! I have always wondered about the "mechanism" versus "medicine" distinction between antidepressants when it comes to how they work and side-effects. SSRI's all tend to cause many similar wanted and unwanted effects. If they isolated the *active* isomer, then they probably isolated something that is *more* likely to cause typical SSRI wanted and *unwanted* effeects. It will be interesting to see the comments made here when people start "reporting" in about it.
> >
> > Mitch
> >
*** i dont get it...in 1 breath..the generic not being available til 2005 is stated, and in the next "patent beating" is thrown out? pick one (hint...its not patent beat) Next...the starting dose for Lex is 10mg...slightly higher in comparison to the higher titrated 40mg of Celexa...compare those side-effects equally, not the higher 20mg of Lex. (and its still "comparable to placebo" per the FDA)...And to understand this "new" drug is to know your isomer science..not this patent crap. (the Nobel Prize for chemistry was won in 2001 for the scientists who developed the technology Forest is using to create Lexapro...and at a lower cost than Celexa too.)
PS....you're right Mitch...only time will tell and then the truth will be known....so lets just watch and see.
Posted by pharmrep on August 20, 2002, at 0:06:06
In reply to Re: Lexapro is no different from Celexa, posted by Patson on August 19, 2002, at 23:10:54
> I might guess that you sound an awful lot like a friend of mine who is a glaxo rep.... He's been telling me the same thing....
>
> > The Danish Institute for Rational Pharmacotherapy has reviewed all of the available data comparing Lexapro and Celexa and has concluded there is no convincing evidence for any difference in tolerability, efficacy, or anything else. This is the only other independent review of the data apart from Micromedex I am aware of. It is only those linked with the manufacturers of Lexapro that are talking it up, and the only two independent reviews come to the same conclusion - there is no real difference. The story is on the Reuters news website.
> >
> >
> ** I have never seen so much hype. I dont know what the Danes are looking at. There are 9 studies so far, and every one shows Lexapro at an advantage. There are more studies on the way...most new drugs only look at placebo, but Lex did head to head right away...do you really think Forest would hang its hat on a drug 3 years before a proven winner (Celexa) if it wasnt better?
PS your Glaxo rep just went through what your describing...paxil cr is the same molecule as paxil...only a lower dose, and different delivery...but the same drug---exactly the same (and passed FDA 3 years ago, but was only released this year..when 1st paxil expires..hows that for patent beat!)..Lexapro is not the same as Celexa... stop the hype and read the studies on your own before making an "informed" decision for yourself.
Posted by dr. dave on August 20, 2002, at 5:21:03
In reply to Re: Lexapro is different » Patson, posted by pharmrep on August 20, 2002, at 0:06:06
'Celexa' 20mg is 10mg s-isomer and 10 mg r-isomer. The r-isomer is effectively inert as an SSRI or anything else. Celexa only works because of the 10mg s-isomer in it. 'Lexapro' is the 10mg s-isomer on its own. It's pretty hard and expensive to produce separately, and it's a funny thing to do when the r-isomer has virtually no pharmacological action at all.
Lexapro 10mg is Celexa 20mg with 10 mg of an inert substance expensively removed.
Posted by dr. dave on August 20, 2002, at 5:31:12
In reply to How do you act on that information? » dr. dave, posted by Anyuser on August 19, 2002, at 11:12:18
I am a practicing psychiatrist and I prescribe Celexa widely. I have a responsibility not to prescribe everything that is claimed to be new and improved until I have some decent scientific information to justify changing from using drugs that I am familiar with.
It is true that Zoloft is more effective than Paxil for some people (as an example), and we don't know why, but we can fairly safely say that it is because they are different drugs which work slightly differently. My puzzlement about claims that Lexapro works better than Celexa are founded on the fact that the active element is the exact same molecule, atom for atom.
The financial issue is relevant as there will always be some limit on the funds available for treating mental disorder. I think that as much benefit should be obtained from those resources as possible. I don't think we can afford to waste money. Paying significantly more for a drug on the basis that the manufacturers think it is better is not justifiable unless there is decent evidence to back that claim up. To date that evidence does not exist.
Posted by dr. dave on August 20, 2002, at 5:48:24
In reply to Re: Lexapro is different » Patson, posted by pharmrep on August 20, 2002, at 0:06:06
I'm sure you believe Lexapro is different, pharmrep, but can't you see that you might not be in a position to make the most balanced of judgements on the evidence? It is not really convincing to try to persuade people it is different just by insisting that it is.
Turning to the isomer science, why are there no plausible theories at all as to how removing r-citalopram could increase speed of onset and efficacy? We know it doesn't affect the pharmacokinetics of s-citalopram and we know that it has about 1/30th the affinity for the serotonin reuptake transporter of s-citalopram so it can't be competing at the binding site. It really is inert. Lundbeck, who developed the drug, still had no theory to back up the claim that r-citalopram impedes s-citalopram's activity when I last spoke to them. Does Forrest?
I would be more than happy to discuss the deficiencies in the published papers if you wish. Independent reviews of the evidence wouldn't both come to the same conclusion for no reason.
Posted by Ritch on August 20, 2002, at 9:37:03
In reply to Citalopram pharmacology - Mitch, posted by dr. dave on August 20, 2002, at 5:21:03
> 'Celexa' 20mg is 10mg s-isomer and 10 mg r-isomer. The r-isomer is effectively inert as an SSRI or anything else. Celexa only works because of the 10mg s-isomer in it. 'Lexapro' is the 10mg s-isomer on its own. It's pretty hard and expensive to produce separately, and it's a funny thing to do when the r-isomer has virtually no pharmacological action at all.
>
> Lexapro 10mg is Celexa 20mg with 10 mg of an inert substance expensively removed.
<from other post>
We know it doesn't affect the pharmacokinetics of s-citalopram and we know that it has about 1/30th the affinity for the serotonin reuptake transporter of s-citalopram so it can't be competing at the binding site.
Thanks for those added tidbits of information! I knew that r-citalopram had less affinity for the serotonin reuptake transporter, but not 1/30th... Then, the only thing left to consider is the notion of r-citalopram *causing* side-effects (commonly associated with SSRI's) with little affinity for the serotonin reuptake transporter.Mitch
Posted by pharmrep on August 20, 2002, at 11:16:11
In reply to Citalopram pharmacology - Mitch, posted by dr. dave on August 20, 2002, at 5:21:03
> 'Celexa' 20mg is 10mg s-isomer and 10 mg r-isomer. The r-isomer is effectively inert as an SSRI or anything else. Celexa only works because of the 10mg s-isomer in it. 'Lexapro' is the 10mg s-isomer on its own. It's pretty hard and expensive to produce separately, and it's a funny thing to do when the r-isomer has virtually no pharmacological action at all.
>
> Lexapro 10mg is Celexa 20mg with 10 mg of an inert substance expensively removed.*** i'm afraid your wrong...if you look at the studies, you'll see that 10mg Lex is 40mg of Celexa, not 20mg....It is not hard, but a new technology that has allowed the separation of the 2 isomers, and it is not that expensive...in fact Lexapro will be less than Celexa...Dr Dave...where do you get your info?
Posted by pharmrep on August 20, 2002, at 11:23:58
In reply to Re: How do you act on that information?, posted by dr. dave on August 20, 2002, at 5:31:12
> I am a practicing psychiatrist and I prescribe Celexa widely. I have a responsibility not to prescribe everything that is claimed to be new and improved until I have some decent scientific information to justify changing from using drugs that I am familiar with.
>
> It is true that Zoloft is more effective than Paxil for some people (as an example), and we don't know why, but we can fairly safely say that it is because they are different drugs which work slightly differently. My puzzlement about claims that Lexapro works better than Celexa are founded on the fact that the active element is the exact same molecule, atom for atom.
>
> The financial issue is relevant as there will always be some limit on the funds available for treating mental disorder. I think that as much benefit should be obtained from those resources as possible. I don't think we can afford to waste money. Paying significantly more for a drug on the basis that the manufacturers think it is better is not justifiable unless there is decent evidence to back that claim up. To date that evidence does not exist.**** I agree that decisions should be based on scientific evidence, and also what reality shows in your pracitice. Lexapro is more than just 1/2 of Celexa, in the studies, it is shown that the r-citalopram was actually inhibiting the s-citalopram from its full potential. As far as cost...Lexapro (a new drug) will be less than Celexa....who told you otherwise? (Lexapro competitors?) There are several studies out that show evidence supporting all the claims you say dont exist..have you read them? Do you know them? I can get them for you if you like so you can make a more "informed" decision.
Posted by Anyuser on August 20, 2002, at 11:31:53
In reply to Re: Dr, where do you get that information? » dr. dave, posted by pharmrep on August 20, 2002, at 11:23:58
Posted by pharmrep on August 20, 2002, at 11:38:30
In reply to Lexapro still isn't different - pharmrep, posted by dr. dave on August 20, 2002, at 5:48:24
> I'm sure you believe Lexapro is different, pharmrep, but can't you see that you might not be in a position to make the most balanced of judgements on the evidence? It is not really convincing to try to persuade people it is different just by insisting that it is.
>
> Turning to the isomer science, why are there no plausible theories at all as to how removing r-citalopram could increase speed of onset and efficacy? We know it doesn't affect the pharmacokinetics of s-citalopram and we know that it has about 1/30th the affinity for the serotonin reuptake transporter of s-citalopram so it can't be competing at the binding site. It really is inert. Lundbeck, who developed the drug, still had no theory to back up the claim that r-citalopram impedes s-citalopram's activity when I last spoke to them. Does Forrest?
>
> I would be more than happy to discuss the deficiencies in the published papers if you wish. Independent reviews of the evidence wouldn't both come to the same conclusion for no reason.*** Yes, and I've gone through credibilty before here. I find it interesting...all the opinions that are subjectively based. If I see statements that are completely one-sided...I like to jump in. Especially ones I have facts on. I have plenty of studies to back the differences up...do you? The 9 done all show statistically significant differences, so what are you referring to when you make your statements. (Did you participate in "early studies?") I am guessing you havent read the studies... primarily because you insist there is no pharmacokinetics in r-citalopram. Yes is does not help in the treatment of depression, but it definitely was inhibiting s-citalopram (ie...r attaches to histomine receptors sites which can cause somnolence). And Lundbeck just spoke to Forest in late June in Atlanta (I was there) about the "US" studies and how more was uncovered than in the European studies. Cool, I would love to chat with you...what city are you in?
Posted by pharmrep on August 20, 2002, at 11:42:31
In reply to Re: Citalopram pharmacology -Dr. Dave, posted by Ritch on August 20, 2002, at 9:37:03
NO.....10mg Lex is 40mg of Celexa...trust me.
Posted by Anyuser on August 20, 2002, at 12:17:02
In reply to Re: Citalopram pharmacology -Dr. Dave » Ritch, posted by pharmrep on August 20, 2002, at 11:42:31
The prescribing info recommends 10mg, period, including elderly patients and those with impaired livers or kidneys. It is interesting to note that the prescribing info says there seems to be no benefit to 20mg over 10mg.
I'm curious, why even bother to manufacturer 5mg pills? The 10 mg pills are scored. Has any testing been done on the 5mg dose?
Posted by Mr.Scott on August 20, 2002, at 13:00:21
In reply to Re: Citalopram pharmacology -Dr. Dave » Ritch, posted by pharmrep on August 20, 2002, at 11:42:31
I am reposting this because even though I haven't picked out anything in your posts that cross any lines you are by definition biased. If your not here for help with a mental disorder it's kind of silly that your here at all. Yes for many, Lexapro will work as an antidepressant, and for some it will not, and other still will have problems with it entirely.. To think it will be light years ahead of anything currently available is preposterous. Everyone is different and your studies with 10,000 patients by doctors who are paid in grants and whose funding has been "underwritten in educational disguise" have consistently failed to elucidate the whole picture on any of these meds when used on a given individual. I would be a no see doc if I was one. Donuts for my office staff and samples for my patients, otherwise... well anyways my post below is what Forest's real goal is. If a few suffering people can benefit than great.
Citalopram is the #1 most used AD in the world
Forest has the marketing rights to Citalopram in the US under Celexa, but not in Europe where it actually is the number 1 prescribed antidepressant. In Europe and all other non-us companies, citalopram is owned by various other companies.
Forest will have full international rights to Lexapro and will launch a campaign to convert the entire world on Citalopram (Celexa and other names) to the new improved Leaxapro. Much more marketshare and money.
Believe me when I tell you that there is not a single person in the pharmaceutical industry who cares about you and your depression as much as they care about you and your money. Their motivations are always 100% based on bottom line revenue. Don't ever think for a second they have any other motivation whatsoever. Altruism is not welcome in this industry. Thats what Church on Sunday is for...
Scott
Posted by Ritch on August 20, 2002, at 13:10:54
In reply to Re: Citalopram pharmacology -Dr. Dave » Ritch, posted by pharmrep on August 20, 2002, at 11:42:31
> NO.....10mg Lex is 40mg of Celexa...trust me.
PharmRep,
I wished somebody would do receptor affinity profiling for r- and s- citalopram separately. If the r- isomer has little affinity for the serotonin reuptake transporter, it (the r-isomer) possibly could have an increased affinity for other receptors involved with side effects. I did find it interesting in the micromedex link posted a while ago that the half-life of s-citalopram is about 22 hrs and that the half-life of s+r-citalopram is about 35 hrs. (If that is inaccurate-please somebody correct me).
thanks,Mitch
Posted by pharmrep on August 20, 2002, at 14:40:38
In reply to Question re dose » pharmrep, posted by Anyuser on August 20, 2002, at 12:17:02
> The prescribing info recommends 10mg, period, including elderly patients and those with impaired livers or kidneys. It is interesting to note that the prescribing info says there seems to be no benefit to 20mg over 10mg.
>
> I'm curious, why even bother to manufacturer 5mg pills? The 10 mg pills are scored. Has any testing been done on the 5mg dose?no...not yet...10 is the starting and maintenance dose...20 if 10 looks a little "light." What do you mean 20mg no benefit? where did you read this?
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