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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 128 to 152 of 8406. Go back in thread:
Posted by Dinah on August 21, 2002, at 17:14:21
In reply to PHARM REP! Why do you care?! » pharmrep, posted by LLL on August 21, 2002, at 16:38:32
> Where have I been? Why? Unlike those who have resonded to me on this board with their kindness and concern regarding my issues and to whom I feel totally indebted and grateful, you are just a salesperson. I see you no differently than the person who recently sold me a car. .
> So please don't ask where I am or say you miss me. You're attempt to garner new consumers for your product is very thinly veiled.Hi. Dinah here. I understand that you are frustrated, but please let's keep this discussion about ideas, and please don't jump to conclusions about the motives of others. Here is a link to Dr. Bob's civility guidelines.
http://www.dr-bob.org/babble/faq.html#civil
Thanks,
DinahP.S. Follow ups regarding posting policies, and complaints about posts, should be redirected to Psycho-Babble Administration. Thanks again.
Posted by LLL on August 21, 2002, at 18:00:34
In reply to relax » LLL, posted by pharmrep on August 21, 2002, at 17:01:37
Posted by Dr. Bob on August 21, 2002, at 18:55:54
In reply to relax » LLL, posted by pharmrep on August 21, 2002, at 17:01:37
> if all you want to do is throw a tirade
I know it's not exactly a warm reception you've received here, but please don't post anything that could lead others to feel accused or put down.
I also completely agree with what IsoM said earlier regarding staying focused on information:
http://www.dr-bob.org/babble/20020821/msgs/117290.html
Thanks,
Bob
Posted by Dr. Bob on August 21, 2002, at 19:09:09
In reply to Two weeks is a hell of a long time to take! (nm) » pharmrep, posted by LLL on August 21, 2002, at 18:00:34
> Two weeks is a hell of a long time to take!
Dinah already asked you to follow the civility guidelines here, which include not posting anything that could lead others to feel accused, so I'm going to block you from posting for a week.
Bob
PS: As Dinah also said, follow-ups regarding posting policies should be redirected to PBA. Here's a link:
Posted by Seamus2 on August 21, 2002, at 22:44:04
In reply to Re: R-isomers vs L-isomers » Bill L, posted by IsoM on August 21, 2002, at 16:17:25
>>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.<<
This doesn't sound possible from my rudimentary knowledge of chemistry.Seamus
PS -- send me an email and tell me what ticked you off about PB so much! Enquiring minds want to know...
Posted by pharmrep on August 21, 2002, at 22:57:22
In reply to Re: Sanchez study » pharmrep, posted by IsoM on August 21, 2002, at 17:14:18
> Do you have a link to this study you mention (the Sanchez study - microdialysis study comparing citalopram (celexa), s-citalopram (lexapro), r-citalopram and placebo)? I can find no info on it & would like to read it over.
>
> And please don't start using expressions like "nice one" or "bravo" as if this is some debate as who's right & who's wrong. It's not. It certainly won't win you any support with such expressions.
>
> I'd like to see this kept as objective as possible so discerning readers can cut through the crap & judge the facts for themselves. It's not a popularity contest, but should remain as dispassionate as possible. I don't wish to see challenges or arguments but simply good questions & answers for information, & sources to back it up so we can make an informed decision ourselves.**my bad..you're right..I want objectivity too, so no more "agreement" comments. As for Sanchez...I havent found it online yet, but will let you know when I do.
Posted by IsoM on August 22, 2002, at 1:47:46
In reply to Re:chirality » IsoM, posted by Seamus2 on August 21, 2002, at 22:44:04
My knowledge of chemistry isn't great either but I read lots & so come across interesting bits. I've read about the renewed interest & uses for thalidomide & have followed it with interest. Here's a link about its ability to change isomers:
http://www.chm.bris.ac.uk/motm/thalidomide/optical2iso.html
and more about thalidomide, if you're interested:
http://www.ama-assn.org/special/hiv/newsline/briefing/thalido.htmExpect an email from me tomorrow giving you my reasons for being 'ticked off' about PB & Bob's policies, & some news too.
Posted by dr. dave on August 22, 2002, at 4:58:29
In reply to Three points, and then I'll drop this » dr. dave, posted by Anyuser on August 21, 2002, at 11:02:21
About point three - please expand on your concerns about my apparently poorly evolved practice and relationships with my patients. I just wonder what you are inferring from my comments in terms of how you think I relate to my patients.
> 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 dr. dave on August 22, 2002, at 5:23:48
In reply to Re: Three points, and then I'll drop this » Anyuser, posted by dr. dave on August 22, 2002, at 4:58:29
I've just seen my first patient who has been taking Lexapro 10mg for a month and says it has only very slghtly helped. He has asked for 'something stronger' although I offered the option of increasing the dose of Lexapro. This is just one patient, so pretty much meaningless in trying to establish Lexapro's overall characteristics, but I don't want it to be thought I wouldn't pursue Lexapro with someone who had started it if that's what they wanted, or that I wouldn't start it if someone particularly wanted to.
With regard to pharmrep's comments about my remote location - I'm not sure how it's relevant to a discussion about this antidepressant. The important thing is attempting to look at the facts objectively.
Why do I keep mentioning expense? I have explained this. With limited resources, it makes sense to spend them wisely, which I think means not paying for more expensive treatments unless it's clear they're more beneficial. In Europe, generic citalopram is at most 75% the cost of Lexapro.
I don't agree the side-effect profile is more favourable. Partly this is because Lundbeck are saying the side-effect profiles are the same. They are specifically not claiming any improved side-effect profile. Sometimes I do accept what the reps tell me.
There are new figures on side-effect rates in citalopram because they were measured at the same time as the Lexapro figures, in the studies analysed by Gorman. Strangely, they don't seem to have been publicised at all, nor are they included in the paper. This would seem very relevant information, wouldn't it?
Posted by Anyuser on August 22, 2002, at 10:01:06
In reply to Re: Three points, and then I'll drop this » Anyuser, posted by dr. dave on August 22, 2002, at 4:58:29
> About point three - please expand on your concerns about my apparently poorly evolved practice and relationships with my patients. I just wonder what you are inferring from my comments in terms of how you think I relate to my patients.
I see that the way I wrote my third point is insulting, but I meant no insult and I apologize. No excuse, but I was running out of time when I wrote it.
Let me ask you a question. If I scheduled an appointment with you, and you diagnosed depression, and I told you I wanted a prescription for Lexapro, and I told you why (along the lines of what I've said in my previous posts), and money wasn't an issue for me, would you give me the prescription? Perhaps along with your caveat that you think I'm wasting my (or my insurer's) money?
Another question. In your practice, when making a decision about treatment for an individual patient, are you required by professional ethics or governmental regulation to factor in social policies regarding public resources available for mental health, or are such concerns personal to you? Do such concerns arise from your employment situation? Perhaps you work in a public hospital with uninsured patients, I don't know. I don't know anything about, what do you call it, National Health in the UK.
What I'm getting at is that I hear you saying that there is in your thinking a convergence of science and public policy. That is, the science behind Lexapro is deficient and it would be wrongful, in a social sense, to waste money, anbody's money, on such an enterprise.
If I asked you for Lexapro on grounds that it might be somewhat better but in any event no worse than Celexa, and I said money is no issue, and you said to me, "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." I would say, in the US, hey Dr. Dave, that's between me and United Health Care, and ultimately, I suppose, between United Health Care and Forest Labs. I wouldn't want my private physician factoring public policy issues into the decisions he makes about my treatment. I care about such public policy issues, but I would discuss them and act upon them outside my doctor's office ("President Hillary in '04!").
Posted by dr. dave on August 22, 2002, at 10:25:36
In reply to Allow me to rephrase . . . . » dr. dave, posted by Anyuser on August 22, 2002, at 10:01:06
To answer your first question, if there was no obvious reason not to prescribe an SSRI I would definitely prescribe Lexapro. It is, in my view, effectively identical to Celexa which is a very good antidepressant which I prescribe all the time. I would tell you my views on it though. I think I would do this even though it would not cost you anything but would cost the National Health Service extra money.
Second question - I am not forced to factor in social policies in my decision making, but there is encouragement to use common sense in terms of not changing prescribing habits unless there is reasonable justification. There is a general consensus I think that if two treatments are equivalent, in general the cheaper should be used - that just seems sensible for everybody. Our health service is free and universal, and paid for out of general taxation. It's not Utopia for sure, but everyone gets equal access to treatment.
In private practice of course the issue of expense has very different implications. If you were paying or an insurance company was paying, that's absolutely your own business, and as I have said Lexapro is undoubtedly a good antidepressant - because it is the same as Celexa.
The most important thing is the science and the evidence. I'm pretty happy to prescribe most things that have a reasonable evidence base behind them if a patient is particularly keen, even if I don't think it is necessarily the most appropriate.
I would however reserve the right to present my own and others' appraisal of the evidence, and point out when they seem consistently different depending on whether you are financially involved e.g Micromedex and Danish Medicines Authority vs. Forest and Lundbeck.
> > About point three - please expand on your concerns about my apparently poorly evolved practice and relationships with my patients. I just wonder what you are inferring from my comments in terms of how you think I relate to my patients.
>
> I see that the way I wrote my third point is insulting, but I meant no insult and I apologize. No excuse, but I was running out of time when I wrote it.
>
> Let me ask you a question. If I scheduled an appointment with you, and you diagnosed depression, and I told you I wanted a prescription for Lexapro, and I told you why (along the lines of what I've said in my previous posts), and money wasn't an issue for me, would you give me the prescription? Perhaps along with your caveat that you think I'm wasting my (or my insurer's) money?
>
> Another question. In your practice, when making a decision about treatment for an individual patient, are you required by professional ethics or governmental regulation to factor in social policies regarding public resources available for mental health, or are such concerns personal to you? Do such concerns arise from your employment situation? Perhaps you work in a public hospital with uninsured patients, I don't know. I don't know anything about, what do you call it, National Health in the UK.
>
> What I'm getting at is that I hear you saying that there is in your thinking a convergence of science and public policy. That is, the science behind Lexapro is deficient and it would be wrongful, in a social sense, to waste money, anbody's money, on such an enterprise.
>
> If I asked you for Lexapro on grounds that it might be somewhat better but in any event no worse than Celexa, and I said money is no issue, and you said to me, "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." I would say, in the US, hey Dr. Dave, that's between me and United Health Care, and ultimately, I suppose, between United Health Care and Forest Labs. I wouldn't want my private physician factoring public policy issues into the decisions he makes about my treatment. I care about such public policy issues, but I would discuss them and act upon them outside my doctor's office ("President Hillary in '04!").
Posted by Bill L on August 22, 2002, at 10:30:09
In reply to First clinical experience with Lexapro, posted by dr. dave on August 22, 2002, at 5:23:48
You said that your patient said that Lexapro only slightly helped. Helped compared to what? Was he previously taking Celexa? If so, what dose and for how long?
Posted by dr. dave on August 22, 2002, at 10:35:50
In reply to First clinical experience with Lexapro, posted by dr. dave on August 22, 2002, at 5:23:48
OK, I've just found figures comparing side-effects for Celexa and Lexapro - they are from a promotional leaflet from Lundbeck and represent combined figures from four studies.
Ejaculation disorder is slightly more frequent with Lexapro than Celexa, as is insomnia, somnolence, upper respiratory tract infection and dizziness. Conversely headache, nausea, diarrhoea, dry mouth, influenza-like symptoms, rhinitis and sinusitis were slightly more common with Celexa than Lexapro.
All of these differenced do not seem to meet statistical significance.
Posted by Dinah on August 22, 2002, at 10:51:31
In reply to Allow me to rephrase . . . . » dr. dave, posted by Anyuser on August 22, 2002, at 10:01:06
I really appreciate the request for clarification and the apology and rephrasing.
That's the sort of thing that will make Dr. Bob's time away go much more smoothly.
So "Thanks for being civil" Dr. Dave and Anyuser. :)
Dinah
Posted by Anyuser on August 22, 2002, at 11:06:12
In reply to Sexual side-effects of Lexapro, posted by dr. dave on August 22, 2002, at 10:35:50
It is certainly true that what Lundbeck has to say on Cipralex.com is not very exciting, and not altogether consistent with the FDA-approved statements that Lexapro is effective at 10mg with s/e equivalent to placebo. I could not find the brochure you mentioned. For those poor souls who can't get enough of this topic, it is interesting to compare what's said on Lexapro.com and Cipralex.com. The differences must reflect what is allowed by the UK and US regulatory authorities. Also, no cartoons in the UK. Get with it, over there!
Posted by pharmrep on August 22, 2002, at 11:54:43
In reply to Cipralex » dr. dave, posted by Anyuser on August 22, 2002, at 11:06:12
> It is certainly true that what Lundbeck has to say on Cipralex.com is not very exciting, and not altogether consistent with the FDA-approved statements that Lexapro is effective at 10mg with s/e equivalent to placebo. I could not find the brochure you mentioned. For those poor souls who can't get enough of this topic, it is interesting to compare what's said on Lexapro.com and Cipralex.com. The differences must reflect what is allowed by the UK and US regulatory authorities. Also, no cartoons in the UK. Get with it, over there!
** It's not what the regulating agencies allowed or not...but that there are some different studies done at a later date that had some different results. Look at the "package insert" info for Lexapro to see the incidence of occurence and compare it to Celexa's. That is one way to compare....but remember Celexa was done over 5 years ago...and for example, sexual side effects was not as hot a topic as it is today...and all of the percentages were "volunteered," so Celexa at 6% was understated (more like 20%) and Lexapro at 9% (more accurate...maybe in the teens) does not necessarily denote an increase...in fact it is most likely a decrease.
Bottom line....only time (and doctor/patients experiences) will tell the true effectiveness of this new antidepressant. Will it be a miracle-drug...probably not...does it initially appear to work faster, with less side effects and less drug interactions compared to the rest of the AD's (including Celexa)? Yes. But it will take more time to prove itself. So since it is not even out in the US yet, and usage in the rest of the world is not enough to make a judgement yet...let's stop hypothesising and just wait and see. (We would all love to hear of any input DR Dave or anybody has as you get the opportunity to try it.)
Posted by Anyuser on August 22, 2002, at 12:48:14
In reply to Re: Cipralex/Lexapro » Anyuser, posted by pharmrep on August 22, 2002, at 11:54:43
What do you understand to be typical dosages for WB augmentation of Celexa?
Posted by pharmrep on August 22, 2002, at 15:33:19
In reply to Question re cel-wel » pharmrep, posted by Anyuser on August 22, 2002, at 12:48:14
> What do you understand to be typical dosages for WB augmentation of Celexa?
* I have heard different ideas from multiple Dr's. The Celexa side doesnt matter since 20-60mg is tolerable for most patients. The Wellbutrin in where they differ...50-150 is the range...most of the concern is if patients are prone to seizures...Wellbutrin could be a prob.
Posted by Anyuser on August 22, 2002, at 16:43:50
In reply to Re: Question re cel-wel » Anyuser, posted by pharmrep on August 22, 2002, at 15:33:19
What do you understand to be the typical dose of Celexa? How often is 20mg prescribed? Do you know if pdocs typically prescribe a lower dose for maintenance, less than the therapeutic dose?
Does Forest have any expectation that some pdocs, presumably those that prescribe lower doses of Celexa, will prescribe 5mgs of Lexapro?
Thanks for your help. I am interested in your view of what practitioners do with your product. If you don't know the answers, that's fine.
Posted by pharmrep on August 22, 2002, at 17:26:50
In reply to More dosage questions » pharmrep, posted by Anyuser on August 22, 2002, at 16:43:50
> What do you understand to be the typical dose of Celexa? How often is 20mg prescribed? Do you know if pdocs typically prescribe a lower dose for maintenance, less than the therapeutic dose?
>
> Does Forest have any expectation that some pdocs, presumably those that prescribe lower doses of Celexa, will prescribe 5mgs of Lexapro?
>
> Thanks for your help. I am interested in your view of what practitioners do with your product. If you don't know the answers, that's fine.** Celexa rx's are as follows; 10mg-20mg=63% 30mg-40mg=32% 40mg+=5%. In my experience..General practitioners and Internists will use 20-40mg but refer out to psychs if not helping. My psychs are not afraid to go higher at all...20-40 is routine..i have many who write 60-80 (there are a few studies that show 80mg without probs) I even have a few that have gone to 100+.
As for Lexapro..the indications are pretty clear, and dosing is easy...10mg for everybody as the starting and maintenace dose...they are scored if you want to go to 15 or a 20 mg tab is available. As for 5mg...no studies yet, probably wont be since 10mg appears to be close to 40mg of Celexa. Since so many other AD's have a "titration" regimen...10 and 20 might seem too easy.(and only 1 wk needed before titrating if needed). Remember, the studies showed 1-2 wks for most patients and efficacy will be seen. Some Dr's might try 5mg to start, but the efficacy probably wont be the same since all the studies were done at 10 and 20mg
Posted by Anyuser on August 22, 2002, at 17:39:26
In reply to Re: dosage » Anyuser, posted by pharmrep on August 22, 2002, at 17:26:50
What's curious to me is that nearly 2/3 of practitioners prescribe 20mg Celexa or less, and we're told that 10mg Lexapro=40mg Celexa, yet there seems to be no expectation that any practitioner would prescribe less than 10mg Lexapro.
Oh well. Time will tell. Thanks for your answers.
Posted by moxy1000 on August 22, 2002, at 19:04:13
In reply to Re: First clinical experience with Lexapro, posted by Bill L on August 22, 2002, at 10:30:09
I have done thorough research on Lexapro and am impressed so far by the clinical data. Nine positive studies and zero negative studies (for example, studies where Lexapro didn't work) were submitted to the FDA. That is a record for any new drug application. As far as it being a "miracle drug" - probably not. It's not really based on cutting edge technology, but based on clinical data alone, it looks like it will work more efficiently then anything else available on the market today. (Ane when I say efficient, I mean it will work more quickly and w/ fewer side effects.) The side effect profile of this drug looks like that of a vitamin. And you can apparently take it w/o any real risk of drug interactions, so that's good if you're taking several different meds. Plus, I understand from one of my friends at Walgreen's, it is priced less then any branded SSRI (including Celexa). In short, when you consider the withdrawal complaints from paxil and effexor, the weight gain complaints from paxil and remeron, the black box warning that serzone has, the nausea caused by zoloft, the drug interactions caused by prozac, and the significant seizure risk associated with wellbutrin, Lexapro looks pretty good. No drug is perfect for everybody, but this looks like it will be worth a shot.
Just my two cents.
Posted by pharmrep on August 22, 2002, at 20:20:05
In reply to Re: dosage » pharmrep, posted by Anyuser on August 22, 2002, at 17:39:26
> What's curious to me is that nearly 2/3 of practitioners prescribe 20mg Celexa or less, and we're told that 10mg Lexapro=40mg Celexa, yet there seems to be no expectation that any practitioner would prescribe less than 10mg Lexapro.
>
> Oh well. Time will tell. Thanks for your answers.*** Remember...in the studies, it was found that the r-citalopram is actually inhibiting the s-citalopram from working to its fullest capability. (Did you see the Sanchez microdialysis study?) That is why it doesnt take as much s-citalopram (Lexapro) to be as/or more effective than 40mg of Celexa. It's all about effectiveness and tolerability
Posted by pharmrep on August 22, 2002, at 20:25:46
In reply to Lexapro clinical data, posted by moxy1000 on August 22, 2002, at 19:04:13
> I have done thorough research on Lexapro and am impressed so far by the clinical data. Nine positive studies and zero negative studies (for example, studies where Lexapro didn't work) were submitted to the FDA. That is a record for any new drug application. As far as it being a "miracle drug" - probably not. It's not really based on cutting edge technology, but based on clinical data alone, it looks like it will work more efficiently then anything else available on the market today. (Ane when I say efficient, I mean it will work more quickly and w/ fewer side effects.) The side effect profile of this drug looks like that of a vitamin. And you can apparently take it w/o any real risk of drug interactions, so that's good if you're taking several different meds. Plus, I understand from one of my friends at Walgreen's, it is priced less then any branded SSRI (including Celexa). In short, when you consider the withdrawal complaints from paxil and effexor, the weight gain complaints from paxil and remeron, the black box warning that serzone has, the nausea caused by zoloft, the drug interactions caused by prozac, and the significant seizure risk associated with wellbutrin, Lexapro looks pretty good. No drug is perfect for everybody, but this looks like it will be worth a shot.
>
> Just my two cents.** Hi there...do you have access to the studies online? I only have hard copies and cant find links to share here...can you help?
Posted by Anyuser on August 22, 2002, at 21:40:58
In reply to Re: dosage » Anyuser, posted by pharmrep on August 22, 2002, at 20:20:05
I get it that 10mg of Lexapro is supposed to be equivalent to 40mg Celexa. However, two thirds of practitioners prescribe less than 40mg Celexa. If you buy the 10=40 equivalence, there is a sizeable difference between the potency of Lexapro that Forest recommends and apparently expects to be prescribed and the potency of Celexa that 2/3 of doctors prescribe today.
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