February 6, 2007

Geodon Is Not BID

If one more person tells me Geodon "doesn't do anything," I'm going to choke them with the capsules.  If it's never worked in your practice, how do you explain the numerous efficacy studies?  All flukes?  All of them?  It couldn't be you?

Probably everyone has heard Geodon must be taken with food.  But that's not to prevent nausea or protect the stomach lining, it's to get the drug to be absorbed.

You'll have to take my word for it right now that 120mg is the a base dose. (120mg Geodon=10mg Zyprexa=3mg Risperdal.)  This is amazingly hard for psychiatrists to appreciate ("there are equivalences?  And those are the doses??")  But it's even harder to get them to understand the relationship to food: Geodon needs fat to be absorbed.


 geodon food


80mg on an empty stomach (blue line) gets you the equivalent of 40mg if taken with food.  That's half the dose.  In other words, if you dose your Geodon "all at night" (no food) then you're getting about half of what you thought you were.  (In chronic dosing this will be less of a problem, but 30-50% increased absorption with food is a good guideline.)

Hospitals: they dose BID, which means morning and night, which means no food either time.  Guess what happens (or doesn't). 

BTW, crackers won't do it.  The graph above is with 800 calories, 400 calories of fat.  That's a meal, not juice.

If your doctor gives you less than 120mg and then gives up, he doesn't understand the proper dosing of Geodon. If he doesn't know about the importance of food, then you're in big trouble.  Forget about reading journals, he's not even listening to the reps. (I know: because they're biased.)

I bring this up partly as a public service message, but also to explore the curious observation that even though many doctors know this already, they still don't dose with food.  I can't imagine laziness is the answer.  There is some weird thinking that this isn't relevant in the "real world" because food is weaker than medication.  Drug-drug interactions matter; drug-food couldn't be important.    And if it was really important, someone e would have mentioned it.

Everyone complains about diabetes and weight gain; here's a drug that likely doesn't have these problems.  But because it doesn't have those toxicities, it therefore can't be "strong," or effective.  

I'm not trying to advocate for Geodon.  I'm pointing out that much of our perception of a treatment's efficacy can come simply from our mishandling of it; and to alert humanity to the inherent bias in ourselves.  If we've never gotten Geodon to work, then not only do we think it doesn't work, but we think everyone who says it does work is a Pfizer schill.

Seroquel had this problem, too.  Six years ago, no one used Seroquel.  Now everyone uses it.  Did they improve it?  No.  It's marketing, but in reverse: Astra Zeneca didn't delude everyone into thinking it works when it doesn't; we deluded ourselves into thinking it didn't, when it did.  So whose fault is that?  Depakote: six years ago Depakote was untouchable, it was the king of bipolar treatment.  Now?   Did we get new data saying don't bother?  Did they make the drug weaker?   This is the key: the data that brings us today's conclusions is the exact same data that gave us the past's, opposite, conclusions.  In other words, no one actually read the data; they based their conclusions on something else.  Clinical experience?  No.

The bias goes well beyond "Pfizer paid that doctor off"-- it comes from a belief system ("meds are life savers" vs. "meds are band-aids"; nature vs. nurture; your own race/gender; your family history of mental illness/drug abuse (or lack of it); your desire to be a "real doctor" etc, etc) that is much deeper and exerts a much stronger control over your thinking.  To the exclusion of any new information.

And, of course, it's so much a part of you that you don't see it as a bias.   And other people (patients) don't know it's there, so they're at the mercy of your unexamined assumptions. 

The solution is exhausting, and no one will like it: constant critical re-evaluation of your beliefs.  Both the science (as much of it as there is) and countertransference.  And, most importantly, long looks at your own identity.  How did you come up with it?  Because, in fact, you did.



The reality is that complia... (Below threshold)

February 6, 2007 7:46 PM | Posted by Anonymous: | Reply

The reality is that compliance with antipsychotics in truly psychotic people is a huge problem, thus a medicine which adds obstacles (like taking something with food) does nothing to address this issue, which is the primary hurdle to be overcome in crippling, debilitating psychotic disorders. Of course, the side effect profile of geodon is good, but then again its also good for abilify...why not just go with that one? And that one works for mood disorders too (if you believe the pharma funded literature) so then you don't even have to try to clinically differentiate the two. Is there data on Geodon for bipolar, I haven't seen anything too convincing.

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You're right that those of ... (Below threshold)

February 7, 2007 3:58 PM | Posted by Lily: | Reply

You're right that those of us who are patients are; "at the mercy of [the psychiatrist's] unexamined assumptions." I am trying to get my psychiatrist to reevaluate my treatment regimen because I refuse to just go on taking the same thing over and over over a period of months or years without periodically reexamining my progress or lack thereof. I pay him too much ($190 a visit) for him to sit on his laurels and not re-think things especially when I think there is a problem.
My curent DXes are MDD and Borderline + anxiety and I am on 300mg lithium, 50mg paroxetine, and 1mg clonazepam qhs.

BTW, do you have children? I just had to ask. I hope that if you do, you have a good relationship with them and they are well adjusted. I would hate to think that your post on psychiatrists' children resulted from projection on your part.

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Although I'm no big fan of ... (Below threshold)

February 8, 2007 10:58 AM | Posted by Dr DJ: | Reply

Although I'm no big fan of the pharmaceutical industry, you are right in that pharma bashing is becoming fashionable. It is just another way of repressing the ingrained prejudices that you mentioned back into our unconscious. I think that this is the key thing, the bias in our beliefs are hidden deep. All the 'look how cool I am I've dissed the reps' attitude is just one defence mechanism to the uneasiness we feel when a patient challenges us with no response to treatment.

On a side note, I don't think I've ever met a patient that's compliant with BD Quetiapine, I don't know about Geodon as we don't have it here in the UK ;)

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Compliance is a problem, bu... (Below threshold)

February 8, 2007 8:38 PM | Posted by Admin: | Reply

Compliance is a problem, but that's why it is so important to get right the one dose the patient does take. I don't know many patients who are compliant with qd, let alone BID-- in fact, a good portion of them take all meds as prns. We can say this isn't acceptable, but it's a reality and I figure why not work within reality?

Semi-responding to Lily-- I have an intellectual understanding of some of the main hazards in parenting, and am even better at deducing where things went wrong. But I am neither a hypocrite nor am I arrogant: I have no delusion that I am/will be a good father. Everything is a learning process, and the sooner I learn it, the better.

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And Dr. J-- I have nothing ... (Below threshold)

February 8, 2007 8:39 PM | Posted by Admin: | Reply

And Dr. J-- I have nothing to add to your comment. It pretty much sums it up.

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That makes sense. I will re... (Below threshold)

April 29, 2007 11:17 AM | Posted by Danielle: | Reply

That makes sense. I will remember to eat with it from now on...thank you!

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I will sure try this see if... (Below threshold)

May 1, 2007 9:59 PM | Posted by Paul: | Reply

I will sure try this see if there is a difference! sure can't hurt

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I am diagnosed schizophreni... (Below threshold)

June 16, 2007 9:33 AM | Posted by Cindy: | Reply

I am diagnosed schizophrenic and I take 60mg of Geodon twice a day with food, although I haven't been making sure it was 800 calories for breakfast. I can assure you that it does work and doesn't zombie me out like Zyprexa did. I am grateful to my doctors for prescribing it to me.

Admin's response: the point I'm making is not that you need 800 calories per dose; but rather that you shouldn't take it on an empty stomach.

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