 Treatment Algorithms --
June 2008
 In This Issue...
Introduction:
Major depression is the most prevalent psychiatric disorder,
affecting approximately 17 million people in the United States and costing tens
of billions of dollars in lost productivity every year. While the majority of
cases can be treated pharmacologically, patient noncompliance is a key barrier
to therapy. First- and second-line therapy for major depression primarily
consists of selective serotonin reuptake inhibitors (SSRIs) (e.g., Forest
Laboratories/Lundbeck’s Lexapro [escitalopram]) or serotonin/norepinephrine
reuptake inhibitors (SNRIs) (e.g., Wyeth’s Effexor XR [venlafaxine, extended
release] and Eli Lilly’s Cymbalta [duloxetine]). However, for patients who do
not respond to these drugs, physicians are turning to a more-aggressive approach
to treatment, most often by giving combination therapy (e.g., with bupropion
[GlaxoSmithKline’s Wellbutrin, generics] or with Bristol-Myers Squibb/Otsuka
Pharmaceutical's Abilify [aripiprazole]). Substantial opportunity exists for
agents that can—either alone or in combination—improve upon the efficacy and/or
side-effect profiles of SSRIs and SNRIs.
Questions Answered in This Report:
- Lines of therapy: The SSRI Lexapro captures more
first-line patients than any other therapy for major depression, but data
suggest it is losing share in earlier lines of therapy compared with data
in last year’s report. Which agents are benefiting the most from Lexapro’s
declining first-line patient share? In what line of therapy do SNRIs capture
the most patient share? How has their ability to gain share in earlier lines of
therapy changed year over year? Which atypical antipsychotic, when used as an
adjunct, retains the most patients?
- Pathways to key therapies: Patients taking Effexor XR and
Cymbalta have substantially different therapeutic histories, reflecting
physicians’ different opinions of these drugs. Which drugs are most often
used directly before Effexor XR and Cymbalta and how have these patterns
evolved over time? When choosing an SNRI, what clinical features that
differentiate agents in this drug class are most important to psychiatrists
versus PCPs? How do psychiatrists and PCPs differ in their opinions on Effexor
XR versus Cymbalta?
- Physician behavior: Psychiatrists treat major depression
more aggressively than do PCPs, more often using combination therapy and more
quickly turning to off-label use of antipsychotics. How has PCPs’ use of
antipsychotics changed over the past year? What are the major reasons
physicians add an antipsychotic to the treatment regimen of a depression
patient, and how do these reasons differ by specialty? Which antipsychotics are
most favorably viewed on each important clinical axis (e.g., control of
agitation) and how can their manufacturers’ best capitalize on these
differences?
- Forecast: Surveyed psychiatrists and PCPs say they will
shift their use of SNRIs to earlier lines of therapy and increasingly use
antipsychotics to treat major depression. Which SNRIs will benefit most from
a shift to earlier lines of therapy? Which drugs will be replaced by Pristiq
(desvenlafaxine), a newly approved SNRI from Wyeth? Will psychiatrists and/or
PCPs use antipsychotics as monotherapy for major depression? Are physicians
aware of Novartis/Servier’s Valdoxan (agomelatine), Sanofi-Aventis’s Saredutant,
and GlaxoSmithKline/NeuroSearch’s GSK-372475?
Includes:
Primary research: Quantitative results from our
survey of 150 physicians (75 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: Lexapro,
Paxil CR, Effexor XR, Cymbalta, Abilify, Seroquel, Risperdal, Zyprexa, Symbyax,
sertraline, fluoxetine, citalopram, paroxetine IR, venlafaxine IR, bupropion, mirtazapine,
benzodiazepines, non-benzodiazepine GABA-A agonists, modified cyclics,
tricyclic agents, lithium, other atypical antipsychotics, and fluvoxamine.
- Flowcharts tracking the preceding therapy patterns for patients
taking each of the following key therapies: Lexapro, Paxil CR, Effexor XR,
Cymbalta, Abilify, Seroquel, Risperdal, Zyprexa, Symbyax, sertraline,
fluoxetine, citalopram, paroxetine IR, venlafaxine IR, bupropion, and
mirtazapine.
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