Olanzapine (Zyprexa)
Second generation antipsychotic (dopamine, serotonin receptor antagonist (D2, 5-HT2))
- Mania/mixed2 (13+)
- Depression augmentation (with fluoxetine)3
- Psychotic depression2
- PTSD augmentation3
- Schizophrenia2 (13+)
- Use after first failed antipsychotic in schizophrenia (then clozapine)
- High dose (25-50 mg) for treatment resistant schizophrenia
Features
Dosing
Antidepressant augmentation (2.5-5 mg/d), Bipolar depression (6-12 mg with fluoxetine 25-50 mg), Mania/mixed (5-15 mg), Schizophrenia (10-2 mg), OCD (2.5-5 mg, but also may worsen OCD), PTSD augmentation (15 mg).
INTERACTIONS: Raise by 2-3x if using with carbamazepine.
Management
Only about 50% gain a lot of weight on it, and If they gain ≥ 5% of weight after 1 month they are likely to be in that group. Consider adding metformin then (unlike Lybalvi, the olanzapine-samidorphan combo, metformin improves weight and metabolic problems).
Use for psychotic depression if first antipsychotic (eg, aripiprazole), does not work.
In PTSD and OCD, the risks usually outweigh the benefits unless there are psychotic symptoms.
TOLERABILITY: Weight gain, sedation, akathisia, EPS (dystonia, stiffness), anticholinergic.
RISKS: Tardive dyskinesia (25% over 10 years, higher in elderly), metabolic, prolactinemia (can lead to breast cancer, osteopenia, sexual dysfunction), orthostasis (falls), QTc prolongation, temperature imbalance in elderly, NMS (muscle rigidity, fever, tachycardia).
EMR Text
Bipolar
Olanzapine use based on FDA approval in bipolar disorder.
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.
Schizophrenia
Olanzapine use based on FDA approval in schizophrenia, and trials showing greater efficacy size for this antipsychotic.
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.
Unipolar depression
Olanzapine use based on trials in antidepressant augmentation and FDA-approval for treatment resistant depression in combination with an antidepressant (Brunner E et al, Neuropsychopharmacology. 2014;39(11):2549-2559).
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.
Psychotic depression
Olanzapine use based on trials in psychotic depression (Meyers BS et al, Arch Gen Psychiatry 2009;66(8):838-847).
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.
PTSD
Olanzapine use based on controlled augmentation trials in PTSD (Liu XH et al, Psychiatry Res. 2014;219(3):543-549).
Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.