The atypically popular atypical antipsychotics

We know one thing for sure that’s typical for the atypical (or second generation) antipsychotics. They’ve caught on like a house on fire.

The atypicals are the top-selling class of drugs today, with revenues in 2010 of about $14.6 billion and $18.2 billion in 2011. They have even surpassed the blockbuster statins that treat high cholesterol (think Lipitor) and drugs that treat reflux (yes, even the Purple Pill), which seems almost inconceivable, given how many people take the take high cholesterol and reflux medicine..


In fact, the fifth and sixth best-selling prescription pills currently in the U.S. are two atypicals: Abilify and Seroquel. Does anyone else but me find this completely astonishing? (Of course, if you saw the price tag these two carried, you’d understand how they worked their way to the top. In fact, fewer prescriptions are written for Abilify, but it beats out Seroquel in revenue, due to its staggering cost.)

The number  of scripts of atypicals per year grew to 54 million in 2011 from 28 million in 2001, an 93% increase.

And their usage strays frequently from their original FDA approvals, which are for schizophrenia.

Use of antipsychotics for illnesses without FDA approval increased from 4.4 million in 1995 to 9.0 million in 2008–and continues to go up with each passing year.

Interestingly, from 1995-2008 there was a 45% decrease in the proportion of the atypicals  used for schizophrenia–the original source of their approval–and a seven-fold increase in use for bipolar disorder, which then made up one-third of all use of the atypical antipsychotics.

Trends in Use of Second-Generation Antipsychotics for Treatment of Bipolar Disorder in the United States, 1998–2009,” just published in this past month’s Psychiatric Services, illuminates how quickly and radically the shift in prescribing patterns in favor of the atypicals has been vis-a-vis bipolar disorder. 

Researchers studied data from a representative audit of 4,800 office-based physicians in the U.S.

Their unit of analysis was what they termed the ‘treatment visit,’ which they defined as “a visit in which bipolar affective disorder was diagnosed and treated with one or more pharmacotherapy.”

Their findings might surprise you.

Note the following:

  • The percentage of treatment visits which resulted in an atypical being prescribed  for bipolar disorder increased from 18% in 1998 to 49% in 2009, an increase of 167%.
  • In the 12 months following approval of Zyprexa, a fairly early and originally quite popular atypical, its use increased by 92%, and use of other atypicals  increased by 42%.
  • Treatment visits where an atypical was used as the only pharmacological treatment (lithium be damned) increased from 7% in 1998 to 27% in 2009.
  • And–get this–the percentage of visits in which an atypical was used with a mood stabilizer went from  77% in 1998 to 47% in 2009. That means that by 2009 more than half (53%) of visits involving an atypical did not include a mood stabilizer.

And that doesn’t begin to address what goes on in other parts of the world.

Atypical antipsychotics are the most expensive drugs prescribed for bipolar disorder in Europe, too, contributing nearly three-fourth of the revenues of the European bipolar disorder therapeutics market, which was valued at $1.20 billion in 2011.

Nor does it address the pediatric market. researchers found that nearly 50% of children treated as inpatients for psychotic and mood disorders are given atypical antipsychotics.

Outpatient visit rates increased radically early on, as well, with those for atypicals in patients under 20 quadrupling between 1997 and 2002.

Since 1993, the rate of antipsychotic drug prescribing to children increased 8-fold, and prescriptions for teens quintupled and in adults nearly doubled. That data almost solely addresses the atypical antipsychotics.

We may not fully know how superior the atypicals are to the first-generation antipsychotics, we may not be able to predict how many more atypicals will be coming up drug-makers’ pipelines, we may not have insight into how the patent cliff will affect the makers of these treatments (Zyprexa, Risperdal and Clozaril are all already off patent)–but we surely do know that atypicals have succeeded in bringing in revenue beyond what must have been the wildest expectations of the first scientist who thought: “What if we created a molecule that would treat schizophrenia, without causing EPS symptoms? Maybe that would that change the world of psychiatry.”

Maybe, indeed.

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