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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 2 of 2. This is the beginning of the thread.
Posted by Christ_empowered on September 26, 2013, at 17:28:56
My doc kinda sorta wanted me on amoxapine (she didn't push it hard, but...still...), so I got to thinking: why bother making disability pay for abilify, when I could just take amoxapine or low-dose loxapine?
Any thoughts on this? I used to order generic Abilify from India for like 30-40ish/month, and that was for 30mgs/day. Now on disability, the taxpayers are paying nearly 1,000/month for 20mgs tablets, and the TD risk isn't nearly as low as was initially believed.
Just a thought. If I could use either amoxapine or loxapine in place of Abilify, my overall med combo would come down to less than $150/month in cost to the tax payers. With all the antioxidants on board, that would reduce the TD risk considerably (Orthomolecular is a really, really good idea if you're on psych meds, btw).
My concern, I guess, would be hormonal effects. Seems like those are common with many antipsychotics at an effective dose :-(
Any thoughts?
Posted by LouisianaSportsman on September 28, 2013, at 13:11:14
In reply to loxapine? amoxapine?, posted by Christ_empowered on September 26, 2013, at 17:28:56
Let's examine this.
Please share your diagnosis and your current psychiatric medication "cocktail". It'll better help me assess what should be done in terms of the usage of either loxapine or amoxapine.
Your pdoc is suggesting the tetracyclic antidepressant, amoxapine, which as you know is a metabolite of loxapine; therefore, it should produce effect similar antipsychotic effects, but it would be weaker antipsychotics than its cousin, loxapine.
I agree with the pdoc's suggestion. It's typically good to go with the pdoc's suggestion since they have the experience and knowledge of your particular case. I believe your pdoc is correct in suggesting amoxapine over loxapine since it acts more as an AAP (atypical antipsychotic) more similarly to aripiprazole (Abilify).
It is clear that you need an antipsychotic, perhaps atypical, if you find aripiprazole therapy effacious.
Neuropsychopharmacology. 2005 Dec;30(12):2236-44.
Amoxapine as an atypical antipsychotic: a comparative study vs risperidone. It concluses that: These data support previous reports about the efficacy of amoxapine as an atypical antipsychotic. Since amoxapine is off-patent, it may be a valuable low-cost alternative to new atypical antipsychotics, particularly in low-income countries where the majority of the patients are still treated with typical antipsychotics. -- this seems to be the effect you're seeking in terms of an aripiprazole replacement.I am unsure if amoxapine can be an effective replacement for Abilify. Abilify's partial agonist effect is one of the strongest indicators of effectiveness in patients-- especially as an adjunct to a typical antidepressant. I wish I knew what your regimen was. Abilify, in my opinion, is the most dynamic drug on the market due to its unique mechanism of action that allows partial agonism and a reduction of side effects compared to other AAPs. It is a hard drug to replace since its so unique. Of course, you have Ziprasidone (Geodon), Lurasidone (Latuda) and Asenapine(Saphris) to consider; however, these are not offered as generics-- therefore, if Abilify is effacious then it would make no sense to switch to these on-patent AAPs at this time if you're looking for a more cost-effective replacement. BUT IMPORTANT: ziprasidone, lurasidone, and asenapine are the best replacements for aripiprazole. You're treading in murky waters by switching to amoxapine as a replacement for your aripriprazole therapy. How effective is aripiprazole for your symptoms? I wouldn't see the need the switch if it's effacious. I know you want to save tax-payer dollars, but your mental health comes first.
Amoxapine would be my choice as the best substitute among the options you provided. Loxapine, regardless of its amoxapine metabolite, acts as a typical antipsychotic, aripiprazole acts an atypical antipsychotic. I think your pdoc knows his stuff in terms of a transfer to amoxapine.
You're right-- amoxapine does cause less extrapyramidal effects. An Update of Fast-Off Dopamine D2 Atypical Antipsychotics. Am J Psychiatry 2005;162:1984-a-1985. doi:10.1176/appi.ajp.162.10.1984-a: The data for the rapidly dissociating antipsychotics (amoxapine, aripiprazole, clozapine, perlapine, quetiapine, remoxipride, and paliperidone) are compatible with their low extrapyramidal signs.
Theoretically, let's say that you switch to loxapine. The binding (Ki [nM])of loxapine at 5-HT targets is much less than that of aripiprazole, but amoxapine, the better option, has great binding at certain 5-HT receptors, more similar to aripiprazole. We need to observe the effects of amoxapine specifically at the 5-HT1A receptor. This is a receptor that Buspirone (Buspar) binds to strongly providing, based on literature-- anxiolytic effects. Amoxapine has negligible affinity for 5-HT1A which shows that it may not be a proper replacement for aripiprazole treatment. Loxapine is in the same boat.
Conclusionally, I agree with your pdoc, based on the evidence I provided, that amoxapine would be the best candidate amongst these two options due to its pharmacological profile. However, do not expect it to completely replicate aripiprazole as well as other AAPs (that may not be as cost-effective).
Also, you can consider generic Seroquel (Quetiapine) as an alternative that is cost-effective, but it comes with an array of side effects that you may not experience with the amoxapine, but the amoxapine does have a significant binding profile with the H1 histamine receptor which will lead to increased initial somnolence comparatively to aripiprazole.
Amoxapine is the better option, in my opinion. Loxapine carries more hardcore side effects. With amoxapine you're getting a concomitant antidepressant/neuroleptic response which is similar to the PI advice for aripiprazole.
Disregarding the expensive AAPs, amoxapine is the best choice, IN MY OPINION, for a replacement for aripiprazole, but it does not share the partial agonist effect at D2 or the effect on the 5-HT1A receptor that makes Abilify such an efficacious treatment for some patients.
Loxapine should be considered only if you're looking for a more hardcore neuoleptic compared to amoxapine's tetracyclic antidepressant action that also has indications of being a good neuroleptic comparable to aripiprazole.
WAIT!!!! I just found this post by you. Let me address it line by line.
[[[I have Bipolar I w/psychotic features. Currently, the line up is: 1200mgs/Trileptal, 20mgs/Abilify, and 300mgs/Neurontin (100, 3x daily). I also do Orthomolecular.]]]
Your Trileptal dose is low, and I would suggest an increase. Have you considered an alternative mood stabilizer such as lamotrigine (Lamictal)?
[[[I have significant agitation, severe depressive episodes (psychotic features), and severe mania, when I get manic (again, psychotic features).]]]
This is changing my idea of amoxapine being more effective than loxapine -- but only based on this regard. Loxapine seems to be better at treating agitation associated with psychotic features or bipolar I disorder in adults. Amoxapine may be contraindicated with your symptoms here.
[[[I also have a touch of OCD, but it seems secondary to extreme agitation on either end of the mood spectrum. So, my doc mentioned amoxapine. Initially, she said it'd be taken w/ the Abilify, but we talked and she said maybe, if I took it, she could do a switch from Abilify to amoxapine.]]]
Amoxapine is going to give you more side effects, likely, than that of aripiprazole. Also, it is not as proven in Bipolar psychosis/mania compared to loxapine.
[[[What do you all know about this drug? Any personal experiences? What's the TD and EPS risk like compared to Abilify?]]]
The TD and EPS for both amoxapine and loxapine is higher than aripiprazole.
I seem to now be contradicting myself. Based on finding this post, I am more inclined to suggest loxapine. Amoxapine is the better option for alleviating depressive episodes similar to Abilify, but it may actually increase agitation in Bipolar I patients. Source: Amoxapine-Induced Agitation Among Bipolar Depressed Patients. Am J Psychiatry 1982;139:387-387. This study makes me more confident in the choice of amoxapine, but you need to evaluate your agitation.
Therefore, I suggest loxapine concomitantly with the aripiprazole in order to reduce your symptoms. If you're trying to get the effects of aripiprazole to avoid future depressive episodes-- the point I was making at the initial part of my response, then amoxapine would be a better therapy to replace aripiprazole.
Ultimately, I think you should combine a low-dose loxapine with your aripiprazole and consider your mental health over cost benefits. If you're simply trying to replace the effects of aripiprazole, then I suggest amoxapine as indicated in the initial part of my response. It's a tough choice, but consider that amoxapine will likely help control your symptoms as well, but you need to be wary of possible increased agitation. According to another study, Efficacy of amoxapine in psychotic depression. Am J Psychiatry 1983;140:1344-1347. :
Psychotic depression is a distinct clinical entity in that its response to tricyclic antidepressants is poor but its response to tricyclic antidepressant-antipsychotics is better. The authors report the favorable outcome of four patients with psychotic depression treated with amoxapine, a derivative of the antipsychotic loxapine. The elevation of serum prolactin during treatment in three patients suggests that postsynaptic dopamine blockade occurs with amoxapine treatment. This might account for the efficacy of amoxapine in psychotic depression.
To conclude,
Evaluate your situation.
1. Combining low-dose loxapine with aripiprazole would be the best suggestion I could make, but this goes against your idea of cost-effectiveness.
2. Amoxapine is a better replacement for aripiprazole if you do want to go the cost-benefit route. Aripiprazole, according to antimanic response to aripiprazole in bipolar I disorder patients is independent of the agitation level at baseline.(PMID:17915976)draws these conclusions:
Aripiprazole was superior to placebo in reducing the severity of both mania and agitation in highly agitated patients with bipolar I disorder and showed significant antimanic activity in patients with low levels of agitation without increasing agitation. These findings suggest that aripiprazole's antimanic effect is specific and not limited to control of agitation through sedation.
Amoxapine replacement is a better direct alternative to aripiprazole, but you mention that agitation is a problem for you-- and in a limited study, it has been found to increase agitation symptoms. Overall, if you absolutely must go to the cost-benefit route, I suggest amoxapine treatment. You just need to monitor its effects, as with any psychotropic.
Feel free to follow up with questions or concerns to my response. Hope to hear from you!
This is the end of the thread.
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