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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 108 to 132 of 8406. Go back in thread:
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.
Posted by LLL on August 21, 2002, at 16:38:32
In reply to where you been? » LLL, posted by pharmrep on August 20, 2002, at 23:03:56
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. When pharmaceutical companies begin to take an interest in people like me who's lives have been devastated by panic disorder and agoraphobia as opposed to depression - then I'll listen. I'm still getting the message that I need to do more CBT, that maybe if I listen to Claire Weeks tapes a few more times I'll finally get it, that if I try harder and work harder that I'll free myself from this "self-imposed" misery. When the pharm. co's and medical profession begin to put this disorder on the same level of urgency as it does those who suffer from depression - then you'll have my attention. The ONLY drugs that have ever helped me were the good old fashioned MAOI's and xanax. When you come up with a drug that reduces my symptoms to a manageable level (without worsening them as do ALL the SSRI's)with tolerable side effects and no drug dependence let me know. Not only do I have a "mental illness", I seem to have one that's "second class" and still terribly misunderstood and mistreated.
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.
Posted by pharmrep on August 21, 2002, at 16:48:03
In reply to Dr. Dave - where did you get your info?, posted by Bill L on August 21, 2002, at 15:53:13
> 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.** I see a lot more objectivity these days. Did you see the C. Sanchez study done (microdialysis study comparing citalopram (celexa), s-citalopram (lexapro), r-citalopram and placebo?) In this study it was expected that equivalent increases in serotonin levels within the brain would be seen since 4mg of citalopram contains 2mg of s-cit, and 2mg of r-cit; however, s-cit (at 2mg) increased serotonin levels by about 300% as opposed to only about 200% increase in the celexa at 4mg. This finding indicates that the r-cit actually interferes with the ablility of the s-cit to increase serotonin levels in the brain. It is not known why yet, and additional studies are being done.
Posted by pharmrep on August 21, 2002, at 17:01:37
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. When pharmaceutical companies begin to take an interest in people like me who's lives have been devastated by panic disorder and agoraphobia as opposed to depression - then I'll listen. I'm still getting the message that I need to do more CBT, that maybe if I listen to Claire Weeks tapes a few more times I'll finally get it, that if I try harder and work harder that I'll free myself from this "self-imposed" misery. When the pharm. co's and medical profession begin to put this disorder on the same level of urgency as it does those who suffer from depression - then you'll have my attention. The ONLY drugs that have ever helped me were the good old fashioned MAOI's and xanax. When you come up with a drug that reduces my symptoms to a manageable level (without worsening them as do ALL the SSRI's)with tolerable side effects and no drug dependence let me know. Not only do I have a "mental illness", I seem to have one that's "second class" and still terribly misunderstood and mistreated.
> 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.** you know....you asked me about Lexapro and agoraphobia and panic disorder about 2 weeks ago...I was just getting back to you. But nevermind, if all you want to do is throw a tirade at a simple "where you been," since I did see you posting before...sorry for disturbing your peace. (And I do care...so I wont be posting you anymore)
Posted by IsoM on August 21, 2002, at 17:14:18
In reply to nice one » Bill L, posted by pharmrep on August 21, 2002, at 16:48:03
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.
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...
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