 Treatment Algorithms --
August 2008
 In This Issue...
Introduction:
Bipolar disorder (BPD) is a chronic illness characterized by
recurrent episodes of aberrant mood. Episodes can manifest with symptoms of
mania, hypomania (a less severe form of mania), depression, or a mixture of
both depression and mania. Lithium, antiepileptics (including Abbott’s branded
valproic acid Depakote/Depakote ER and GlaxoSmithKline’s Lamictal
[lamotrigine]), and atypical antipsychotics, often taken in combination, are
the mainstay of treatment for BPD. Concern about each of these agents’
side-effect/safety profiles continues to motivate new changes in prescribing
trends. Lithium’s efficacy and low cost
sustain its use in BPD, but interviewed experts report that patient concerns
about side effects have tempered some of its use. Although the FDA issued a
warning about an increased risk of suicidal behavior or ideation with
antiepileptic use in January 2008, only a minority of the psychiatrists and
primary care physicians (PCPs) we surveyed for this report note that these
warnings have changed their prescribing of antiepileptics.
A larger proportion of the physicians we surveyed have
shifted their use of atypical antipsychotics because of the risk of metabolic
and weight gain side effects associated with the use of these drugs. Bristol-Myers
Squibb/Otsuka’s Abilify (aripiprazole) and Pfizer’s Geodon (ziprasidone) are
perceived to be associated with a lower propensity to induce this side effect
compared with AstraZeneca’s Seroquel (quetiapine), risperidone (Janssen’s
Risperdal, generics), and Eli Lilly’s Zyprexa (olanzapine) but are also viewed
as being less efficacious than these other drugs. Seroquel’s approval for
treatment of both poles of BPD—mania and depression—sets this agent apart from
atypical antipsychotics and has helped to establish Seroquel as the market and
patient share leader within this drug class. Using patient-level claims data,
as well as insight from 151 surveyed specialists and PCPs, this report
determines the share of each currently marketed drug by line of therapy, analyzes
why key drugs are chosen over others, and explains how physicians predict that
this dynamic will change over the next two years.
Questions Answered in This Report:
- Lines of therapy: Although most BPD patients are diagnosed
by a psychiatrist, an increasing fraction of BPD patients are being diagnosed
and treated by their PCP. What agents do surveyed PCPs versus psychiatrists
we surveyed prefer as first-line therapies for specific presentations of BPD,
including acute depression associated with BPD I and BPD II, mixed mood, and
acute mania? Based on data from surveyed physicians, which atypical
antipsychotic franchise--Zyprexa, Geodon, or Abilify--retains a higher
proportion of its patients as they transition from intramuscular (for acute
episodes) to oral (for maintenance) agents? How much of early-line drug use is
attributed to Depakote, Depakote ER, lithium, and each atypical antipsychotic? How
much first-line patient share do agents with efficacy against bipolar
depression such as Lamictal and Seroquel gain versus agents prescribed primarily
first line to treat acute mania?
- Pathways to key therapies: BPD is a chronic disease that requires
life-long treatment, and patients often switch between therapies as well as add
drugs to their existing treatment regimens. Which drugs do surveyed psychiatrists
and PCPs prefer as maintenance therapies for BPD I and BPD II? Which atypical antipsychotic
garners the most use as a first-line therapy? What share of patients moving to
Invega (paliperidone; Janssen’s follow-on drug to Risperdal) comes to the drug
after Risperdal versus other atypical antipsychotics? How do the pathways to
each atypical antipsychotic, Depakote, Depakote ER, and Lamictal differ?
- Physician behavior: Surveys of BPD patients have found
that up to 69% of patients are initially misdiagnosed and that many patients
experience a delay of five to ten years before receiving a correct diagnosis. How
many patients who receive a diagnosis for BPD are prescribed drug therapy
within a year of their initial diagnosis? What factors do surveyed PCPs and
psychiatrists believe stand as the key impediments to initiating drug treatment
in BPD patients? What drugs do physicians most frequently prescribe to patients
with subthreshold BPD? What key attributes of Seroquel lead surveyed
psychiatrists and PCPs to choose this drug over Abilify as a treatment for BPD?
What factors influence surveyed physicians to switch patients who have
failed other drugs to Invega?
- Forecast: Surveyed PCPs and psychiatrists say that their
use of atypical antipsychotics will continue to shift through 2010. Which
agents do surveyed PCPs and psychiatrists anticipate will lose and gain patient
share over the next two years? Which agents do surveyed physicians cite as most
likely to lose patient share to generic risperidone? How do their responses
differ by specialty? To what extent will surveyed physicians step up their
first-line use of Invega and AstraZeneca’s Seroquel XR (quetiapine)? What
agents will be replaced by each of these recently launched treatments?
Includes:
Primary research: Quantitative results from our
survey of 151 physicians (76 psychiatrists and 75 PCPs):
- Physician opinion on how drug use differs by patient severity.
- Most influential drug attributes when physicians choose between
agents.
- Anticipated changes in the line of therapy in which physicians
use key agents.
Primary patient-level data: Quantitative findings
from our analysis of data covering 55 million lives from more than 80
geographically diverse U.S. health plans:
- Quantified lines of therapy analysis showing exact share of each
agent in each line of therapy, including rate of progression between lines and
length of time patients are on each line.
- Progression flowcharts through one year of treatment for newly
diagnosed patients receiving each of the following first-line agents: lithium,
Lamictal, Depakote, Depakote ER, other forms of valproic acid, carbamazepine,
Topamax, other antiepileptic drugs, Zyprexa, Zyprexa Zydis, Risperdal,
Risperdal M-tabs, Seroquel, Abilify, Geodon, typical antipsychotics, Lexapro,
other SSRIs, venlafaxine IR, Effexor XR, Cymbalta, mirtazapine, bupropion,
tricyclic agents, trazodone, Symbyax, benzodiazepines, and nonbenzodiazepine
GABA-A agonists.
- Flowcharts tracking the preceding therapy patterns for patients
taking each of the following key therapies: lithium, Depakote, Depakote ER,
other forms of valproic acid, Lamictal, carbamazepine, Topamax, Zyprexa,
Risperdal, Seroquel, Seroquel XR, Abilify, Geodon, and Invega.
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