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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 99 to 123 of 8406. Go back in thread:
Posted by dr. dave on August 20, 2002, at 16:25:16
In reply to where's the love? » dr. dave, posted by pharmrep on August 20, 2002, at 15:58:42
OK, sorry about being snitty about spelling, and I stand corrected on 'Forest'.
I think the Gorman paper is weak. Jack Gorman is paid by Forest. He is also paid by Lundbeck. His paper has only managed to get published in a paper he edits himself. He is not independent of the significant financial pressures surrounding this issue.
Generic citalopram is already available in Europe from what I gather, having been launched in Israel earlier this year.
What city am I in? I'm in a hospital in a little village in the mountains of Wales, at least an hour from anything resembling a city!
> > The statement '10mg Lex is 40mg Celexa' doesn't make any sense. Let's get down to the science here - '10mg lex' is 10mg of s-citalopram. '40mg Celexa' is 20mg s-citalopram plus 20mg r-citalopram. That's different. A study has been presented claiming 10mg Lexapro is as effective as 40mg Celexa - but Jack Gorman in his meta-analysis of the research states that this study was too small to demonstrate differences in efficacy. The result of one small trial is not necessarily the complete and absolute truth.
> >
> > Is the separation expensive? A slow-moving bed plant required to separate stereoisomers costs upward of $5 million. To me, that's expensive.
> >
> > Where do I get my info? From the published studies, which I have looked through thoroughly, and from a knowledge of pharmacology from studying at Cambridge University.
> >
> > The studies SUGGEST certain things, but are very very far from demonstrating them conclusively. Statistical significance of difference is inconsistent across the studies. Lexapro will certainly not be cheaper than generic citalopram which is available in Europe to the best of my knowledge.
> >
> > Although r-citalopram has some affinity to histamine (not 'histomine') receptors this does not mean it is 'inhibiting s-citalopram'. You cannot inhibit a molecule, you can only inhibit a process - which process involving s-citalopram is the r-citalopram/histamine receptor interaction inhibiting?
> >
> > The whole marketing of this drug seems to be based on sloppy science. I have no problem with Celexa, I prescribe it all over the place, but raising desparate people's hopes with woolly and wishful thinking I object to.
> >
> > I would be happy to discuss the shortcomings of any particular study on escitalopram that is publically available if we want to get into the science of it.
>
> ***I agree that the few studies out hardly represent the end-all-be-all of facts, but the 9 out now look promising. Pardon my appreviating...most of my posts I receive are like this, so I do it too. I met Dr. Gorman in June...he spoke for 1 hour and didnt hesitate on the research and efficacy findings. He said Lexapro has greater efficacy. As far as expense of isolating isomers...I dont know what the cost are to Forest...I only know that Lexapro will be less expensive to the patients than Celexa....and there is no generic for Celexa until late 2005 here or Europe. I may have oversimplified my histamine statement, but dont kill me for a typing error. (and it's Forest...not "Forrest")
> Forest hasn't even begun any marketing yet, only a few studies are out to show efficacy, side-effect profile, drug to drug interactions, and tolerablity.... The FDA actually encourages isomer science. What dont you like? I would like to cover the studies with you since you have seen them....typing is too hard...what city are you in?
Posted by Anyuser on August 20, 2002, at 16:37:24
In reply to Receptor affinity profiles of s- and r-citalopram, posted by dr. dave on August 20, 2002, at 16:02:00
A recurring theme on this board is how to obtain reliable information about ADs. As among (1) scientific papers, both pre- and post- governmental approval, (2) clinical experience reported by practitioners, and (3) individual experiences, I would value (2) over (1) and (3). With respect to escitalopram, in the US there is no clinical experience and no individual experience. We patients, at the moment, are limited to the scientific papers. Most knowledgeable patients, and there are many on this board, know that drug applications are written by lawyers for lawyers. The prescribing information for Celexa, for example, is false and misleading with respect to the incidence of sexual side effects. I think a sensible attitude toward escitalopram is to be hopeful but sceptical. It might be enough of an improvement in reducing side effects to keep some number of patients on the drug longer.
You, on the other hand, as a practicing physician in the UK, have access not only to the scientific papers but also to the individual experience of Cipralex users. Moreover, you can get in the game and test the veracity of the scientific papers and the marketing raps by prescribing Cipralex. You say you prescribe Cipramil. You must have patients that suffer sexual side effects. Haven't any of such patients asked you to prescribe Cipralex instead? Let's say you have a patient who's been taking 40mgs of Cipramil and can't have an orgasm and tells you she is going off the drug. Why wouldn't you test Lundbeck's rap by writing a scrip for 10mgs of Cipralex and seeing how it worked for your patient? You don't have to rely on the papers, you can generate your own clinical experience. Why wouldn't you do so?
I'm not arguing the merits of escitalopram here. I don't know the truth. I'll be interested to hear what people say after they try it. You have a chance to try it on your patients and (apparently) choose not to, apparently in reliance meta-surveys. Why? I value your opinion now, but I think your opinion would carry even more weight if you were to say that you've tried Cipralex on your patients and they tell you it's better/worse/the same compared to Cipramil.
Posted by IsoM on August 20, 2002, at 16:51:15
In reply to Re: where's the love?, posted by dr. dave on August 20, 2002, at 16:25:16
It's already available in Sweden, Denmark, Germany, the Netherlands, Finland, Iceland, Israel, the Czech Republic & Australia.
(from http://www.lundbeck.com/investor/Reportsandpresentations/InterimReports/Interim_report_for_the_first_quarter_of_2002.pdf)Seropram was the name that citapolpram was marketed under in Austria, France, Greece, Italy & Spain. It seems that the patent for each name runs out at slightly different times in different countries.
Posted by Dinah on August 20, 2002, at 17:52:04
In reply to Re: where's the love?, posted by dr. dave on August 20, 2002, at 16:25:16
Sorry to interrupt with a tangent. But I just want to say how lovely I think your area is. I don't think there's anywhere in the world I love nearly as much as the mountains of Wales.
I'm envious.
Ok, tangent over.
Very sincerely,
Dinah
Posted by Ritch on August 20, 2002, at 22:16:19
In reply to Receptor affinity profiles of s- and r-citalopram, posted by dr. dave on August 20, 2002, at 16:02:00
Posted by pharmrep on August 20, 2002, at 22:29:21
In reply to Thanks for that pdf link! (nm) » dr. dave, posted by Ritch on August 20, 2002, at 22:16:19
Hi...did you find the Sanchez study done in US?...I saw the Euro one...it's a little different.
Posted by pharmrep on August 20, 2002, at 22:40:06
In reply to Re: where's the love?, posted by dr. dave on August 20, 2002, at 16:25:16
Come on Dr.D. Do you really think Dr. Gorman is going to ruin his reputation in his field and future for a paycheck today. How many studies are done where the Dr. didnt get some kind of "consideration" or grant for his/her time and effort? That would mean we cant trust any study at all. As far as credibility, if the FDA in the US is basing its decision on approving a drug with certain studies, you can bet they check out the credentials of the doctors, and parameters of the study before they put their stamp on it. I stand corrected...it appears that a generic will be available later this year on your side of the world, it wont be in the US until 2005...I see you are in Wales...I am in Southern California...guess we wont be meeting anytime soon (Ha Ha)
Posted by pharmrep on August 20, 2002, at 23:01:33
In reply to Re: Lexapro update, posted by katekite on July 31, 2002, at 10:13:30
Miss you...you ok? Lots of Lexapro talk going on.
Posted by pharmrep on August 20, 2002, at 23:03:56
In reply to Re: Lexapro update » pharmrep, posted by LLL on July 31, 2002, at 13:10:23
Miss you, you ok? Lots of Lexapro talk going on.
Posted by Ritch on August 21, 2002, at 8:53:02
In reply to Re: sanchez microdialysis study » Ritch, posted by pharmrep on August 20, 2002, at 22:29:21
> Hi...did you find the Sanchez study done in US?...I saw the Euro one...it's a little different.
I have it jotted down. I will need to go the library to dig it up (perhaps my pdoc has it). Since the earliest trial of Lexapro I would attempt would likely be early October I am in no big rush. I haven't even went through the European study just yet. I hear they have 5mg tabs. Are those scored? I would be quartering those into roughly 1.25mg chunks if I try the stuff.
Mitch
Posted by dr. dave on August 21, 2002, at 8:58:35
In reply to Knowledge » dr. dave, posted by Anyuser on August 20, 2002, at 16:37:24
This is a good point. I think my stance is that I shouldn't be changing my practice, particularly if it is an expensive change which will unavoidably reduce resources in some other area, until I have reasonable grounds for doing so, and I don't think that I have those grounds to change to Lexapro. If the drug company can't come up with reasonable evidence, with every incentive to do so, I can feel fairly sure there's not much to find.
Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found.
I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence.
I haven't been able to find the data which indicate a lower incidence of sexual side-effects on Lexapro than Celexa - If pharmrep or anyone can point me in the right direction I would be very interested.
Posted by katekite on August 21, 2002, at 11:01:54
In reply to where you been? » katekite, posted by pharmrep on August 20, 2002, at 23:01:33
Dr. Dave seems to have all his ducks in a row. I appreciate that he's taking the time to put forth some straight info that counter-acts what is in my opinion (just my opinion, no personal disrespect intended) misleading information about Lexapro.
Thanks for missing me and enquiring after my whereabouts, Pharmrep. -- kate
PS: keep it coming Dr. Dave!
Posted by Anyuser on August 21, 2002, at 11:02:21
In reply to Re: Knowledge, posted by dr. dave on August 21, 2002, at 8:58:35
1. For all the reasons that are dwelled upon on this board, FDA prescribing info should be viewed skeptically: the FDA is inept, the drug companies are corrupt, lawyers write the thing for lawyers, drug therapy in general is all placebo effect, the science is crap, the studies are too small and too short, etc, etc, etc. The fact remains that in the US there is officially sanctioned prescribing info that states "the overall incidence of adverse effects in 10mg Lexapro treated patients was similar to that of placebo treated patients." On that basis alone, I would not characterize a patient wanting to try that drug or a physician prescribing that drug as "just 'having a go' with something new in case it works."
2. It seems to me that skepticism about the science behind drug approvals can cut both ways. My pdoc, for what it's worth, says that in his clinical experience Serzone is far more effective than the published data indicates. My pdoc happens to be nuts ("barking mad" in the UK?). My point here is not that doctors and patients should hope for benefits not suggested by the scientific data. I do think, however, that clinical experience is a body of knowledge more important than the research data. For example, only 715 patients were tested in the Lexapro research. A busy pdoc would over the course of time have more experience, in absolute terms, with a greater number of patients than the researchers that got the drug approved. For another example, there are meta-surveys out there that "prove" scientfically that all ADs provide only placebo effect, yet you've got patients and practicing physicians that say they don't care what the meta-surveys say, ADs work, however imperfectly.
3. For me, and for most people I know, and for most doctors I know, doctor/patient relationships are evolving beyond what you imply about your practice.
Posted by pharmrep on August 21, 2002, at 11:45:47
In reply to Re: sanchez microdialysis study » pharmrep, posted by Ritch on August 21, 2002, at 8:53:02
I dont know about any 5 mg tabs yet...i would guess maybe 6 months down the road (they are meant to cover the space between 10 and 20, since starting dose is supposed to be 10 for everybody. I understand your specific sensitivity you mentioned before...so maybe 5 or 2.5 is good for you.) As for being scored...I dont know, but probably...I will keep you posted if I can find out more.
Posted by pharmrep on August 21, 2002, at 12:04:44
In reply to Re: Knowledge, posted by dr. dave on August 21, 2002, at 8:58:35
> This is a good point. I think my stance is that I shouldn't be changing my practice, particularly if it is an expensive change which will unavoidably reduce resources in some other area, until I have reasonable grounds for doing so, and I don't think that I have those grounds to change to Lexapro. If the drug company can't come up with reasonable evidence, with every incentive to do so, I can feel fairly sure there's not much to find.
>
> Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found.
>
> I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence.
>
> I haven't been able to find the data which indicate a lower incidence of sexual side-effects on Lexapro than Celexa - If pharmrep or anyone can point me in the right direction I would be very interested.*** You keep mentioning expense...why? Lexapro although new, will cost less than Celexa for your patients. Even if you are not persuaded by the studies you've read that Lexapro has better efficacy...would you agree that the side effect profile and drug to drug interactions and lack of adverse events are even more favorable than Celexa? That alone should be enough. But I know that it will be slow going for some (you included) and thats fine...you can judge for yourself with the patients you do try it with. As for additional studies...the FDA wants specific ones first...efficacy, tolerablity, and others. I know that others are already in the works...(ie head to head Lexapro vs Effexor...etc.) Larger scale studies take more time and will out soon too. As for sexual side effects...the FDA relies on "volunteered" info...so Celexa at 6% over 5 years ago was really more like in the teens-20% (I hear Paxil and Prozac at 30% and above from my dr's) but the awareness then and candidness was not what it is today.
Lexapro at 9% is believed to be a more accurate number since data is less than 1 yr old and the study-patients might have been more apt to site the ejac/delay. But if the number crept up to the low teens...I wouldnt be surprised...Lexapro is still an SSRI, so it will be there...it seems the more selective though, the less the side effects. Only real life practices and experience will be able to reveal a clearer picture.
Posted by pharmrep on August 21, 2002, at 12:10:06
In reply to Where've I been? learning from Dr. Dave., posted by katekite on August 21, 2002, at 11:01:54
> Dr. Dave seems to have all his ducks in a row. I appreciate that he's taking the time to put forth some straight info that counter-acts what is in my opinion (just my opinion, no personal disrespect intended) misleading information about Lexapro.
>
> Thanks for missing me and enquiring after my whereabouts, Pharmrep. -- kate
>
** what ducks? He is in Europe...and has had the opportunity to see for himself what Lexapro/cipralex can do, and hasnt. Has a rep even given him sample in his remote location...I hope they find him. Either way...his opinions are as good as yours or mine...they are not based on real life experiences yet, but only studies. Dont get me wrong..I appreciate his input too, I just wish he would try it, then make a judgement.
Posted by IsoM on August 21, 2002, at 13:28:26
In reply to Re: Knowledge, posted by dr. dave on August 21, 2002, at 8:58:35
Dr. Dave, you've made two good points (the following quotes) but I'd like to show another slightly different argument for the possible use of Lexapro, if you'd like to consider my opinion.
You said:
"Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found."and
"I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence."
--------------------------------
I agree with you completely. BUT... There are always those few where available drugs haven't helped them. We still don't really understand how ADs work, but terms such as "...is thought responsible for its action..." or "...is believed to be related to its selective inhibition..." are used to describe how ADs are thought to work. Until researchers are truly able to understand all that's involved & tailor meds specifically, much of our prescribing treatments are still going to be based on conjecture. As much an art as a science in prescribing.
Even after large scale studies are done, it will be the individual doctors themselves who will be gathering the real data, long-term, on the efficiency of these new drugs in the general population. As you know, the initial studies are done in select groups & don't necessarily represent the ordinary population that will be using these medications long-term.
I know, personally, from my experience & that of my family, that I've appreciated a doctor's willingness to try a different, perhaps not thoroughly tested in the general population, drug. Surprisingly, against all obvious logic, such a drug will be the one that works for such a person where others have failed.
I know you may say that this is not a new drug but only the isomer of one already available, but it may be just the ticket for someone in whom Celexa has previously worked but has caused troublesome side effects - to the point that it was stopped. It may not be the choice for most, but in those few patients, it may be just what is needed.
It's up to doctors like you to be willing to give it a try for a select few, despite costs.
My doctor has never used Provigil (modafinil or Alertec in Canada) before & never heard of it either. But despite that, he was willing to prescribe it for me when asked & it's been a godsend for me. It's prohibitory expensive - costs me about $180/mo, but thankfully the union from my part-time job covers the total expense. Something similar may be true with others too, allowing them to use such expensive meds.
Posted by Anyuser on August 21, 2002, at 14:25:00
In reply to Re: Complete Knowledge Not Always Available » dr. dave, posted by IsoM on August 21, 2002, at 13:28:26
Click here: http://www.lexapro.com/mediacenter/background/default.asp
See "Isomer animation" link
Posted by Dr. Bob on August 21, 2002, at 15:15:09
In reply to Hey Pharm-rep, posted by Mr.Scott on August 20, 2002, at 13:00:21
> 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.
Potential bias is important to take into account when deciding what to trust:
http://www.dr-bob.org/babble/faq.html#trust
But I'd also like people to feel welcome here, so please be sensitive to their feelings:
http://www.dr-bob.org/babble/faq.html#civil
Keep in mind that if you're blocked again, it would probably be for 4 weeks...
Bob
PS: Follow-ups regarding posting policies, and complaints about posts, should be redirected to Psycho-Babble Administration, thanks.
Posted by pharmrep on August 21, 2002, at 15:24:36
In reply to Re: Complete Knowledge Not Always Available » dr. dave, posted by IsoM on August 21, 2002, at 13:28:26
> Dr. Dave, you've made two good points (the following quotes) but I'd like to show another slightly different argument for the possible use of Lexapro, if you'd like to consider my opinion.
>
> You said:
> "Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found."
>
> and
>
> "I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence."
>
> --------------------------------
>
> I agree with you completely. BUT... There are always those few where available drugs haven't helped them. We still don't really understand how ADs work, but terms such as "...is thought responsible for its action..." or "...is believed to be related to its selective inhibition..." are used to describe how ADs are thought to work. Until researchers are truly able to understand all that's involved & tailor meds specifically, much of our prescribing treatments are still going to be based on conjecture. As much an art as a science in prescribing.
>
> Even after large scale studies are done, it will be the individual doctors themselves who will be gathering the real data, long-term, on the efficiency of these new drugs in the general population. As you know, the initial studies are done in select groups & don't necessarily represent the ordinary population that will be using these medications long-term.
>
> I know, personally, from my experience & that of my family, that I've appreciated a doctor's willingness to try a different, perhaps not thoroughly tested in the general population, drug. Surprisingly, against all obvious logic, such a drug will be the one that works for such a person where others have failed.
>
> I know you may say that this is not a new drug but only the isomer of one already available, but it may be just the ticket for someone in whom Celexa has previously worked but has caused troublesome side effects - to the point that it was stopped. It may not be the choice for most, but in those few patients, it may be just what is needed.
>
> It's up to doctors like you to be willing to give it a try for a select few, despite costs.
> My doctor has never used Provigil (modafinil or Alertec in Canada) before & never heard of it either. But despite that, he was willing to prescribe it for me when asked & it's been a godsend for me. It's prohibitory expensive - costs me about $180/mo, but thankfully the union from my part-time job covers the total expense. Something similar may be true with others too, allowing them to use such expensive meds.
*** bravo...nice thoughts...and as for cost for Lexapro...it will be less than Celexa. I would say (according to Dr's I've seen) that they need to switch from one AD to another about 25% of the time (usually based on adverse events, drug-to-drug interactions and side-effects) That is was Lexapro is for...those who want/need to switch and maybe those new patients since the "profile" appears good.
Posted by Bill L on August 21, 2002, at 15:53:13
In reply to Re: Complete Knowledge Not Always Available/bottom » IsoM, posted by pharmrep on August 21, 2002, at 15:24:36
Dr Dave - I have read about the studies on Lexapro but did not see what you claimed to be true. You said that out of a 40mg pill of Celexa, that 20mg is inert. Where did you read that?
I have read that the other isomer is not effective against depression, but I have not read that it is inert.
On the contrary, I have read about 2 different possible actions of the R isomer:
1) it may cause side effects
2) it may interfere with the S isomer (possibly by competing for binding sites or some other mechanism)You claimed that the R isomer is inert and that 20 mg of Lexapro is therefore equivalent to 40mg of Celexa. Since your facts go against other stuff that I have read (ie. items 1 and 2 above), can you tell me your sources? Thanks.
Posted by IsoM on August 21, 2002, at 16:04:27
In reply to Re: Complete Knowledge Not Always Available/bottom » IsoM, posted by pharmrep on August 21, 2002, at 15:24:36
Could you please give a link that I can read over that gives information of the cost of Lexapro vs Celexa, please? You mention that it will be cheaper but I'd like to see it in writing from a reputable source before I completely trust it. I do find it surprising that a new introduction would be cheaper than one already on the market. You must understand that I neither side with you nor Dr. Dave but am still gathering information for myself. I feel there's no 'your' side or 'his' side but just not all the facts yet. I currently take Celexa (along with some other meds) & am following this topic with interest but doing so completely objectively.
Posted by pharmrep on August 21, 2002, at 16:15:33
In reply to Re: Cost of Celexa vs Lexapro » pharmrep, posted by IsoM on August 21, 2002, at 16:04:27
> Could you please give a link that I can read over that gives information of the cost of Lexapro vs Celexa, please? You mention that it will be cheaper but I'd like to see it in writing from a reputable source before I completely trust it. I do find it surprising that a new introduction would be cheaper than one already on the market. You must understand that I neither side with you nor Dr. Dave but am still gathering information for myself. I feel there's no 'your' side or 'his' side but just not all the facts yet. I currently take Celexa (along with some other meds) & am following this topic with interest but doing so completely objectively.
***Good for you...be your own research guide. I'm sorry there's no "price-list" I'm referring to...only the company meeting where we learned about Lexapro/studies/isomer science/etc. It was told to us the despite the costs for making Lexapro...no increase in price...if fact about 10% less. At a place like Costco here in California...20mg Celexa is about $60/mo, so Lexapro should be about $54. As for the rest of the country, the same 10% should apply.
Posted by IsoM on August 21, 2002, at 16:17:25
In reply to Dr. Dave - where did you get your info?, posted by Bill L on August 21, 2002, at 15:53:13
I'd also like to know more about the differences between the two enantiomers of citaprolam.
Enantiomers can be strange objects. Case in point is thalidomide, the anti-nausea medication that was widely prescribed for pregnant women world-wide a few decades ago. It was found that it was the effects of the inert isomer of thalidomide that caused the horrific birth defects in children born to these women. Thalidomide still has potential as a drug in the treatment of rheumatoid arthritis & leprosy, among others. When it was found possible to separate the two isomers in a racemic mix of thalidomide, great hopes were raised for its general use again. But sadly, the pH of the body reverted the single effective isomer back to a racemic mixture in the body with its resultant side effects.
Isomeric chemistry is not always so clear cut & I'd like to pursue more on these two isomers of citaprolam & research being done on the ineffective one.
Posted by IsoM on August 21, 2002, at 16:23:02
In reply to Cost of Celexa vs Lexapro » IsoM, posted by pharmrep on August 21, 2002, at 16:15:33
I live in Canada. I'll wait when it comes out to find what the final price will end up. Sorry, but the best of plans or promises don't always turn out the way they were said to be - even with honest intentions. I'm in no big hurry.
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