Olanzapine (Monograph)

Brand name: ZyPREXA
Drug class: Atypical Antipsychotics
VA class: CN709
Chemical name: 2-Methyl-4-(4-methyl-1-piperazinyl)-10H-thieno[2,3-b][1,5]benzodiazepine
Molecular formula: C₁₇H₂₀N₄SC₂₃H₁₆O₆•C₁₇H₂₀N₄S•H₂0
CAS number: 132539-06-1

Medically reviewed by Drugs.com on Nov 2, 2023. Written by ASHP.

Warning

Risk Evaluation and Mitigation Strategy (REMS):

FDA approved a REMS for olanzapine to ensure that the benefits outweigh the risks. The REMS may apply to one or more preparations of olanzapine and consists of the following: medication guide, elements to assure safe use, communication plan, and implementation system. See https://www.accessdata.fda.gov/scripts/cder/rems/.

Warning

PDSS reported following injections of extended-release olanzapine pamoate (Zyprexa Relprevv); clinical manifestations were consistent with olanzapine overdosage, particularly sedation (including coma) and/or delirium.³⁷² ³⁸² ³⁸³ ³⁸⁶ ³⁸⁷ ³⁹¹ ³⁹² ³⁹⁸
Extended-release olanzapine pamoate must be administered in a registered healthcare facility with ready access to emergency response services.³⁷² ³⁸² ³⁹⁸
After each injection, patients must be observed for at least 3 hours by a healthcare professional.³⁷² ³⁸²
Because of the risk of PDSS, extended-release olanzapine pamoate is available only through a restricted distribution program.³⁷² ³⁸² (See REMS and see Restricted Distribution under Dosage and Administration.)

Geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.¹ ²⁶ ¹⁰¹ ³⁸² ³⁹⁹
Analyses of 17 placebo-controlled trials in geriatric patients mainly receiving atypical antipsychotic agents revealed an approximate 1.6- to 1.7-fold increase in mortality compared with that in patients receiving placebo.¹ ¹⁰¹ ³⁸² ³⁹⁹
Most fatalities appeared to result from cardiovascular-related events (e.g., heart failure, sudden death) or infections (mostly pneumonia).¹ ¹⁰¹ ³⁸²
Observational studies suggest that conventional or first-generation antipsychotic agents also may increase mortality in such patients.¹ ²⁶ ³⁸² ³⁹⁹
Antipsychotic agents, including olanzapine, are not approved for the treatment of dementia-related psychosis.¹ ²⁶ ¹⁰¹ ³⁸² ³⁹⁹

Introduction

Thienobenzodiazepine-derivative; atypical or second-generation antipsychotic agent.¹ ² ⁴ ⁷ ¹⁴ ¹⁶ ¹⁷ ¹⁸ ¹⁹ ²⁰ ²² ²⁶ ¹¹⁹ ³¹⁵ The drug is structurally similar to clozapine.³ ¹⁴ ¹⁶ ²⁰

Uses for Olanzapine

Schizophrenia

Orally (as olanzapine) and IM (as the long-acting olanzapine pamoate ester) for the acute and maintenance treatment of schizophrenia.¹ ² ³ ⁴ ⁶ ⁷ ¹⁴ ¹⁶ ²⁰ ²¹ ²² ²⁶ ¹⁰⁵ ²⁰⁵ ²⁰⁶ ²¹⁹ ²²⁰ ²²¹ ²²³ ²²⁴ ²²⁵ ²²⁶ ²³⁹ ³⁰⁵ ³⁰⁶ ³⁰⁷ ³⁰⁹ ³¹⁰ ³¹¹ ³¹⁵ ³³⁴ ³³⁷ ³⁵⁴ ³⁵⁷ ³⁵⁸ ³⁵⁹ ³⁶⁰ ³⁶¹ ³⁶² ³⁶⁹ ³⁸² ³⁸³ ³⁸⁴ ³⁸⁵

IM (as short-acting olanzapine) for management of acute agitation in patients with schizophrenia for whom treatment with olanzapine is appropriate and who require an IM antipsychotic agent for rapid control of behaviors that interfere with diagnosis and care.¹ ⁹⁸ ¹⁰²

American Psychiatric Association (APA) considers most atypical antipsychotic agents first-line drugs for management of the acute phase of schizophrenia (including first psychotic episodes).²⁶

Patients who do not respond to or tolerate one drug may be successfully treated with an agent from a different class or with a different adverse effect profile.² ²⁶ ²⁸ ⁴⁰⁰

Bipolar Disorder

Orally for acute treatment of mixed or manic episodes associated with bipolar I disorder (as monotherapy and as adjunctive therapy with lithium or valproate).¹ ³⁶ ³⁷ ⁴¹ ¹⁰⁰ ²⁴⁴ ²⁴⁵ ²⁴⁶ ²⁴⁷ ²⁴⁸ ²⁴⁹ ²⁵⁰ ²⁵¹ ²⁵² ³⁰⁸ ³⁷⁰

Orally for maintenance treatment of bipolar I disorder (as monotherapy).¹

Orally for treatment (in combination with fluoxetine) of acute depressive episodes associated with bipolar I disorder.¹ ³¹² ³¹³ ³⁹⁷ Olanzapine monotherapy is not indicated for treatment of depressive episodes associated with bipolar I disorder.¹

IM (as short-acting olanzapine) for management of acute agitation in patients with bipolar I disorder for whom treatment with olanzapine is appropriate and who require an IM antipsychotic agent for rapid control of behaviors that interfere with diagnosis and care.¹ ⁹⁹

Treatment-resistant Depression

Orally for acute and maintenance therapy (in combination with fluoxetine) of treatment-resistant depression (major depressive disorder in patients who do not respond to 2 separate trials of different antidepressants of adequate dosage and duration in the current episode).¹ ³¹²

Not indicated for treatment-resistant depression as monotherapy.¹

Cancer Chemotherapy-induced Nausea and Vomiting

Has been used orally (in combination with other antiemetic agents) for prevention of acute and delayed nausea and vomiting associated with highly emetogenic cancer chemotherapy^{† [off-label]}, including high-dose cisplatin therapy.⁴²⁵ ⁴²⁶ ⁴²⁷ ⁴²⁸

For prevention of nausea and vomiting associated with highly emetogenicchemotherapy regimens (including an anthracycline plus cyclophosphamide), ASCO recommends a 4-drug antiemetic regimen consisting of an NK₁ receptor antagonist (e.g., aprepitant, fosaprepitant, netupitant [in fixed combination with palonosetron], rolapitant), a 5-HT₃ receptor antagonist (e.g., dolasetron, granisetron, ondansetron, palonosetron, ramosetron [not commercially available in the US], tropisetron [not commercially available in the US]), dexamethasone, and olanzapine.⁴²⁵ If the fixed combination of netupitant and palonosetron is used as an NK₁ receptor antagonist, use of an additional 5-HT₃ receptor antagonist is not necessary.⁴²⁵

Clinical experience with oral olanzapine in adults receiving moderately emetogenic chemotherapy is limited;⁴²⁵ ⁴²⁷ ASCO does not recommend olanzapine in such patients.⁴²⁵ For adults receiving carboplatin with a target AUC of ≥4 mg/mL per minute, ASCO recommends a 3-drug antiemetic regimen consisting of an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, and dexamethasone.⁴²⁵ For adults receiving other chemotherapy of moderate emetic risk, excluding carboplatin with a target AUC of ≥4 mg/mL per minute, ASCO recommends a 2-drug antiemetic regimen consisting of a 5-HT₃ receptor antagonist and dexamethasone.⁴²⁵

For chemotherapy regimens with low emetic risk, ASCO recommends a single dose of either a 5-HT₃ receptor antagonist or dexamethasone alone on the first day of chemotherapy.⁴²⁵

For chemotherapy regimens with minimal emetic risk, ASCO states that routine antiemetic prophylaxis is not necessary.⁴²⁵

Olanzapine also has been shown to be an effective rescue antiemetic in patients who develop breakthrough chemotherapy-induced nausea and vomiting^{† [off-label]} despite optimal antiemetic prophylaxis.⁴²⁵ ⁴²⁹

For patients with breakthrough chemotherapy-induced nausea or vomiting, ASCO recommends clinicians reevaluate emetic risk, disease status, and concomitant medical conditions and medications and determine whether the best antiemetic regimen is being provided for the emetic risk.⁴²⁵ In adults who experience nausea and vomiting despite optimal antiemetic prophylaxis and who have not received olanzapine prophylactically, ASCO states that olanzapine may be added to the standard antiemetic regimen.⁴²⁵ In adults who experience nausea or vomiting despite optimal antiemetic prophylaxis and who have already received olanzapine, may add an antiemetic drug from a different class (i.e., an NK₁ receptor antagonist, lorazepam or alprazolam, a dopamine receptor antagonist [e.g., metoclopramide], dronabinol or nabilone) to the standard antiemetic regimen.⁴²⁵

Olanzapine Dosage and Administration

General

Restricted Distribution

Because of the risk of PDSS, extended-release olanzapine pamoate for injectable suspension (Zyprexa Relprevv) is available only under a restricted distribution program, the Zyprexa Relprevv Patient Care Program.³⁷² ³⁸²
The program is designed to ensure that the drug is administered in a registered healthcare facility with ready access to emergency response services and that patients are continuously monitored by a healthcare professional for at least 3 hours following each injection.³⁷² ³⁸²
Clinicians, healthcare facilities, pharmacists, and patients must be enrolled in the program before they can prescribe, dispense, and receive extended-release olanzapine pamoate.³⁷² ³⁸² This formulation must not be dispensed directly to a patient.³⁷² ³⁸²
For additional information and to enroll in the program, contact the manufacturer at 877-772-9390 or visit [Web].³⁷² ³⁸²

Administration

Administer olanzapine orally or by IM injection.¹ ³¹² Administer olanzapine pamoate only by IM injection.³⁸² (See Possible Prescribing and Dispensing Errors under Cautions.)

Establish tolerability with oral olanzapine prior to initiating extended-release olanzapine pamoate IM therapy.³⁸²

Oral Administration

Administer olanzapine orally as conventional tablets, orally disintegrating tablets, or capsules (in fixed combination with fluoxetine) once daily without regard to meals.¹ ³¹² If persistent or troublesome daytime sedation occurs with olanzapine monotherapy for psychiatric indications (e.g., psychotic disorders, bipolar disorder, treatment-resistant depression), consider evening administration.²⁶ ²⁵⁹ Administer fixed-combination olanzapine and fluoxetine capsules (e.g., Symbyax) in the evening.³¹²

Just prior to administration of orally disintegrating tablets, gently remove tablet from blister packet; do not push tablet through foil.¹ With dry hands, peel open blister package, place tablet on tongue to dissolve, and swallow with or without liquid.¹

IM Administration of Short-acting Olanzapine (e.g., Zyprexa IntraMuscular)

Short-acting (immediate-release) olanzapine (10 mg per vial) is used for agitation associated with schizophrenia or bipolar mania; do not confuse this formulation with the long-acting olanzapine pamoate formulation (Zyprexa Relprevv; available in 210-, 300-, and 405-mg vial strengths) used for schizophrenia.¹ ³⁸²

Administer only by IM injection; inject drug slowly and deeply into the muscle mass.¹ Do not administer IV or sub-Q.¹

Reconstitution

Reconstitute short-acting olanzapine for injection by adding 2.1 mL of sterile water for injection to vial containing 10 mg of olanzapine to provide a solution containing approximately 5 mg/mL.¹ Do not use other solutions to reconstitute olanzapine for injection.¹

Use immediately (within 1 hour) following reconstitution.¹ If necessary, the reconstituted solution may be stored for up to 1 hour at 20–25°C; after 1 hour, discard any unused portion.¹

IM Administration of Long-acting Olanzapine Pamoate (Zyprexa Relprevv)

Long-acting olanzapine pamoate (available in 210-, 300-, and 405-mg vial strengths) is used for schizophrenia; do not confuse this formulation with the short-acting (immediate-release) olanzapine formulation (e.g., Zyprexa IntraMuscular; 10 mg per vial) used for agitation associated with schizophrenia or bipolar mania.¹ ³⁸²

Administer only by deep IM injection into the gluteal area; do not administer IV or sub-Q.³⁸² A healthcare professional should administer the injection every 2–4 weeks.³⁸² (See Dosage under Dosage and Administration.)

Following insertion of the needle into the gluteal muscle for the IM injection, aspirate for several seconds to ensure that no blood is drawn into the syringe.³⁸² If blood appears in the syringe, withdraw the needle and discard the syringe and dose.³⁸² Use a new convenience kit for the new dose with a new syringe and needle.³⁸² Do not massage injection site following IM administration.³⁸²

Precautions related to Risk of PDSS

Extended-release olanzapine pamoate must be administered in a registered healthcare facility (e.g., hospital, clinic, residential treatment center, community healthcare center) with ready access to emergency response services.³⁷² ³⁸² (See Post-injection Delirium/Sedation Syndrome [PDSS] in the Boxed Warning and also under Cautions.)

Discuss the potential risk of PDSS with patients and provide a medication guide each time extended-release olanzapine pamoate is prescribed and administered.³⁸² ³⁸⁶

After each injection, continuously monitor patients at the healthcare facility for at least 3 hours.³⁷² ³⁸² Patients should be alert, oriented, and absent of any signs and symptoms of PDSS prior to being released; all patients should be accompanied to their destination upon leaving the healthcare facility.³⁷² ³⁸²

Patients should not drive or operate heavy machinery for the remainder of the day following the injection and should be vigilant for symptoms of PDSS and able to obtain medical assistance if needed.³⁷² ³⁸²

If PDSS is suspected, institute close medical supervision and monitoring in a facility capable of resuscitation.³⁸²

Reconstitution

Consult manufacturer’s labeling for instructions for using components of the Zyprexa Relprevv Convenience Kit for reconstitution of olanzapine pamoate powder for suspension.³⁸² Reconstitute only with diluent supplied by manufacturer.³⁸²

Reconstituted olanzapine pamoate suspension remains stable for up to 24 hours in the vial.³⁸² If not used immediately, shake the vial vigorously to resuspend the drug prior to administration.³⁸²

Dosage

Available as olanzapine and olanzapine pamoate; dosage expressed in terms of olanzapine.¹ ³⁸²

For treatment of psychiatric indications (e.g., psychotic disorders, bipolar disorder, treatment-resistant depression), adjust olanzapine dosage carefully according to individual requirements and response, using the lowest possible effective dosage.¹ ²⁰

Pediatric Patients

Schizophrenia

Oral

Adolescents 13–17 years of age: Initially, 2.5 or 5 mg once daily.¹ May increase to a target dosage of 10 mg daily.¹

Make subsequent dosage adjustments in increments or decrements of 2.5 or 5 mg daily.¹

Effective dosage in clinical studies generally ranged from 2.5–20 mg daily (mean dosage of about 11 mg daily).¹ ³⁶⁹

Optimum duration of therapy not known, but maintenance therapy with olanzapine is well established in adults.¹ In responsive patients, continue the drug beyond the acute response at the lowest effective dosage; periodically reassess need for continued maintenance therapy.¹

Bipolar Disorder

Manic or Mixed Episodes: Monotherapy

Oral

Adolescents 13–17 years of age: Initially, 2.5 or 5 mg once daily.¹ May increase to a target dosage of 10 mg daily.¹

Make subsequent dosage adjustments in increments or decrements of 2.5 or 5 mg daily.¹

Effective dosage in clinical studies generally ranged from 2.5–20 mg daily (mean dosage of about 9 mg daily).¹

Acute Depressive Episodes

Oral

Children and adolescents 10–17 years of age: Initially 2.5 mg in combination with 20 mg of fluoxetine, or 3 mg in fixed combination with 25 mg of fluoxetine (e.g., Symbyax) once daily in the evening.¹ ³¹²

Increase dosage according to patient response and tolerance as indicated to a target dosage of olanzapine 6–12 mg with fluoxetine 25–50 mg daily.¹ ³¹²

If elect to use combined olanzapine and fluoxetine therapy for extended periods, periodically reevaluate the long-term risks and benefits for the individual patient.¹ ³¹²

Adults

Schizophrenia

Oral

Initially, 5–10 mg, usually as a single daily dose.¹ ²⁰ ²⁶ Within several days, may increase by 5 mg daily, to a target dosage of 10 mg daily.¹ ²⁰

Make subsequent dosage adjustments at intervals of not less than 7 days, usually in increments or decrements of 5 mg once daily.¹ ²⁰

Increasing dosage beyond 10 mg daily usually does not result in greater efficacy; such increases generally should occur only after assessment of the patient’s clinical status.¹

Optimum duration of therapy currently is not known, but maintenance therapy with antipsychotic agents is well established.¹ ²³ ²⁵ In responsive patients, continue as long as clinically necessary and tolerated, but at lowest possible effective dosage; reassess need for continued therapy periodically.¹ ²⁰

IM, Extended-release Olanzapine Pamoate

Establish tolerability with oral olanzapine prior to initiating extended-release olanzapine pamoate IM (Zyprexa Relprevv) therapy.³⁸²

For patients established on oral olanzapine 10 mg daily, recommended initial dosage is 210 mg every 2 weeks or 405 mg every 4 weeks for first 8 weeks.³⁸² After 8 weeks, recommended maintenance dosage is 150 mg every 2 weeks or 300 mg every 4 weeks.³⁸²

For patients established on oral olanzapine 15 mg daily, recommended initial dosage is 300 mg every 2 weeks for first 8 weeks.³⁸² After 8 weeks, recommended maintenance dosage is 210 mg every 2 weeks or 405 mg every 4 weeks.³⁸²

For patients established on oral olanzapine 20 mg daily, recommended initial and maintenance dosage is 300 mg every 2 weeks.³⁸²

Efficacy demonstrated in clinical studies within dosage range of 150–300 mg administered every 2 weeks and with 405 mg administered every 4 weeks.³⁸² ³⁸³ ³⁸⁵

A lower initial dosage of 150 mg every 4 weeks recommended in patients who are debilitated, who may be predisposed to hypotensive reactions, who exhibit a combination of factors that may result in slower metabolism of olanzapine (e.g., nonsmoking female patients ≥65 years), or who may be more sensitive to the pharmacodynamic effects of the drug.³⁸²

Optimum duration of therapy not known, but long-term efficacy demonstrated over a 24-week period.³⁸² ³⁸³ In addition, long-term use of oral olanzapine has been shown to maintain treatment response in patients with schizophrenia.³⁵⁴ ³⁸² If used for an extended period, periodically reassess need for continued maintenance therapy.³⁸²

Acute Agitation associated with Schizophrenia

IM, Short-acting Olanzapine

Initially, 10 mg of short-acting olanzapine (e.g., Zyprexa IntraMuscular).¹ Consider lower doses (2.5, 5, or 7.5 mg) when clinically warranted.¹

In clinical trials, efficacy in controlling agitation in patients with schizophrenia or bipolar mania demonstrated in a dosage range of 2.5–10 mg.¹ ⁹⁸ ⁹⁹ ¹⁰²

If agitation persists, may administer subsequent single doses of up to 10 mg.¹ However, efficacy of repeated doses was not systematically evaluated in controlled trials.¹

Assess patients for orthostatic hypotension prior to administration of any subsequent IM doses.¹ (See Orthostatic Hypotension under Cautions.)

If ongoing therapy is indicated, may initiate oral olanzapine 5–20 mg daily as soon as clinically appropriate.¹

Bipolar Disorder

Manic or Mixed Episodes: Monotherapy

Oral

Initially, usually 10 or 15 mg once daily.¹ Make dosage adjustments in increments or decrements of 5 mg daily, at intervals of not less than 24 hours.¹

Effective dosage in clinical studies generally ranged from 5–20 mg daily.¹ ³⁶ ³⁷ ⁴¹ ²⁴⁴ ²⁴⁵ ²⁴⁷ ²⁵⁰ ²⁵²

If elect to use olanzapine for extended periods, periodically reevaluate the long-term usefulness for the individual patient.¹

Manic or Mixed Episodes: Combination Therapy

Oral

Initially, 10 mg once daily when administered with lithium or valproate.¹ ⁴¹

Effective dosage of olanzapine in clinical studies generally ranged from 5–20 mg daily.¹ ⁴¹

No dosage adjustment of lithium or valproate is required when used in combination with olanzapine.¹

If elect to use olanzapine for extended periods, periodically reevaluate the long-term usefulness for the individual patient.¹

Acute Depressive Episodes

Oral

Initially, 5 mg in combination with 20 mg of fluoxetine, or 6 mg in fixed combination with 25 mg of fluoxetine (e.g., Symbyax) once daily in the evening.¹ ³¹²

Increase dosage according to patient response and tolerance as indicated to a target dosage of olanzapine 5–12.5 mg with fluoxetine 20–50 mg daily.¹ ³¹²

In clinical trials, antidepressive efficacy was demonstrated at olanzapine dosages ranging from 6–12 mg daily and fluoxetine dosages ranging from 25–50 mg daily.³¹²

If elect to use combined olanzapine and fluoxetine for extended periods, periodically reevaluate the long-term risks and benefits for the individual patient.¹ ³¹²

Acute Agitation associated with Bipolar Mania

IM, Short-acting Olanzapine

Initially, 10 mg of short-acting olanzapine (e.g., Zyprexa IntraMuscular).¹ Consider lower doses (2.5, 5, or 7.5 mg) when clinically warranted.¹

In clinical trials, efficacy in controlling agitation in patients with schizophrenia or bipolar mania demonstrated in a dosage range of 2.5–10 mg.¹ ⁹⁸ ⁹⁹ ¹⁰²

If agitation persists, may administer subsequent single doses of up to 10 mg.¹ However, efficacy of repeated doses was not systematically evaluated in controlled trials.¹

Assess patients for orthostatic hypotension prior to administration of any subsequent IM doses.¹ (See Orthostatic Hypotension under Cautions.)

If ongoing therapy is indicated, may initiate oral olanzapine 5–20 mg daily as soon as clinically appropriate.¹

Treatment-resistant Depression

Oral

Initially, 5 mg in combination with 20 mg of fluoxetine, or 6 mg in fixed combination with 25 mg of fluoxetine (e.g., Symbyax) once daily in the evening.¹ ³¹²

Increase dosage according to patient response and tolerance as indicated to a target dosage of olanzapine 5–20 mg with fluoxetine 20–50 mg daily.¹ ³¹²

In clinical trials, antidepressive efficacy was demonstrated at olanzapine dosages ranging from 6–18 mg daily and fluoxetine dosages ranging from 25–50 mg daily.¹ ³¹²

Optimum duration of therapy not known; periodically reassess need for continued maintenance therapy.¹ ³¹²

Cancer Chemotherapy-induced Nausea and Vomiting

Highly Emetogenic Cancer Chemotherapy

Oral

For the prevention of acute and delayed nausea and vomiting^{† [off-label]}, usually has been administered as part of a regimen that includes an NK₁ receptor antagonist, a 5-HT₃ receptor antagonist, and dexamethasone.⁴²⁵ ⁴²⁶

Administer 10 mg once daily before chemotherapy on day 1 followed by 10 mg once daily on days 2–4 of chemotherapy.⁴²⁵ ⁴²⁶

Some evidence suggests that 5-mg once-daily doses of olanzapine may be as effective as and less sedating than 10-mg once-daily doses; additional controlled studies are needed to determine optimal dosage.⁴²⁵ ⁴²⁶ ⁴²⁸

Breakthrough Nausea and Vomiting associated with Cancer Chemotherapy

Oral

For the treatment of breakthrough nausea and vomiting^{† [off-label]} despite optimal antiemetic prophylaxis, olanzapine 10 mg once daily has been given for 3 days in a controlled clinical study.⁴²⁹

Prescribing Limits

Pediatric Patients

Schizophrenia

Oral

Adolescents 13–17 years of age: Safety of dosages >20 mg daily not established.¹

Acute Agitation associated with Schizophrenia

IM, Short-acting Olanzapine

Safety of dosages >30 mg daily or of 10-mg doses given more frequently than 2 hours after the initial dose and 4 hours after the second dose not established.¹

Bipolar Disorder

Manic or Mixed Episodes: Monotherapy

Oral

Adolescents 13–17 years of age: Safety of dosages >20 mg daily not established.¹

Acute Depressive Episodes

Oral

Children and adolescents 10–17 years of age: Dosages >12 mg of olanzapine with 50 mg of fluoxetine not evaluated in clinical trials.¹ ³¹²

Adults

Schizophrenia

Oral

Safety of dosages >20 mg daily not established.¹ ²⁰

IM, Extended-release Olanzapine Pamoate

Safety and efficacy of dosages >405 mg every 4 weeks or 300 mg every 2 weeks not established.³⁸²

Acute Agitation associated with Schizophrenia

IM, Short-acting Olanzapine

Safety of dosages >30 mg daily or of 10-mg doses given more frequently than 2 hours after the initial dose and 4 hours after the second dose not established.¹

Bipolar Disorder

Manic or Mixed Episodes

Oral

Safety of dosages >20 mg daily (as monotherapy or combination therapy with lithium or valproate) not established.¹

Acute Depressive Episodes

Oral

Dosages >18 mg of olanzapine with 75 mg of fluoxetine in fixed combination for acute depressive episodes not evaluated in clinical studies.¹ ³¹²

Acute Agitation associated with Bipolar Mania

IM, Short-acting Olanzapine

Safety of dosages >30 mg daily or of 10-mg doses given more frequently than 2 hours after the initial dose and 4 hours after the second dose not established.¹

Special Populations

For treatment of psychiatric indications (e.g., psychotic disorders, bipolar disorder, treatment-resistant depression) in debilitated patients, in those predisposed to hypotension, in those who may be particularly sensitive to the effects of olanzapine, or in those who might metabolize olanzapine slowly (e.g., nonsmoking women ≥65 years of age), an initial oral olanzapine dosage of 5 mg daily, 2.5 mg of short-acting olanzapine IM, or 150 mg of long-acting olanzapine pamoate IM every 4 weeks is recommended; when indicated, adjust dosage with caution.¹ ²⁶ ³⁸²

When used in combination with fluoxetine for acute depressive episodes in bipolar disorder or treatment-resistant depression, an oral dosage of 2.5–5 mg of olanzapine and 20 mg of fluoxetine, or 3–6 mg of olanzapine in fixed combination with 25 mg of fluoxetine (e.g., Symbyax), is recommended in patients predisposed to hypotension, those with hepatic impairment, or those who might metabolize the drugs(s) slowly (e.g., female gender, geriatric age, nonsmoking status); when indicated, adjust dosage with caution.¹ ³¹²

Hepatic Impairment

Manufacturer states that olanzapine dosage adjustment is not necessary in patients with hepatic impairment.¹ (See Pharmacokinetics.)

Extended-release IM olanzapine pamoate (Zyprexa Relprevv) not specifically studied in patients with hepatic impairment.³⁸²

Renal Impairment

Manufacturer states that olanzapine dosage adjustment is not necessary in patients with renal impairment.¹ (See Pharmacokinetics.)

Extended-release IM olanzapine pamoate (Zyprexa Relprevv) not specifically studied in patients with renal impairment.³⁸²

Geriatric Patients

Consider a lower initial dosage of olanzapine in geriatric patients.¹ ³⁸²

Careful dosage titration of oral olanzapine recommended in patients >65 years of age.¹ ²⁶

Consider a lower initial IM dose of 5 mg of short-acting olanzapine.¹

Cautions for Olanzapine

Contraindications

Manufacturer states none known with oral or short-acting IM olanzapine monotherapy or with extended-release IM olanzapine pamoate.¹ ³⁸²
When used in combination with fluoxetine, consider the usual contraindications associated with fluoxetine.¹
When used as adjunctive therapy with lithium or valproate, refer to prescribing information for those other drugs.¹

Warnings/Precautions

Warnings

Post-injection Delirium/Sedation Syndrome (PDSS)

Manifestations consistent with olanzapine overdosage, particularly sedation and/or delirium, reported following extended-release olanzapine pamoate (Zyprexa Relprevv) injection.³⁷² ³⁸² ³⁸³ ³⁸⁶ ³⁸⁷ ³⁹² ³⁹⁸ Reported in <0.1% of injections³⁸² ³⁸⁶ ³⁸⁷ and approximately 2% of patients who received injections for up to 46 months.³⁸² In some cases, the events correlated with a rapid, greater than expected increase in serum olanzapine concentrations to supratherapeutic ranges,³⁸² ³⁸⁷ ³⁹⁸ but the mechanism by which the drug entered the bloodstream is not known.³⁸² ³⁹⁸

Manifestations of PDSS include dizziness, confusion, disorientation, malaise, slurred speech, altered gait, ambulation difficulties, weakness, agitation, extrapyramidal symptoms, hypertension, convulsions, and reduced levels of consciousness (mild sedation to coma).³⁸² ³⁸³ ³⁸⁶ Onset generally has ranged from soon after the injection to >3 hours after the injection; patients have largely recovered by 72 hours.³⁸² ³⁸³ ³⁸⁶

Because the risk of PDSS is the same at each injection, the risk is cumulative (i.e., increases with the number of injections).³⁸² ³⁸⁴

FDA reviewed 2 unexplained deaths that occurred 3–4 days after the patients received an appropriate dose of extended-release olanzapine pamoate (well beyond the REMS-required 3-hour post-injection monitoring period).³⁹¹ ³⁹⁸ Both patients had very high postmortem blood concentrations of olanzapine.³⁹¹ ³⁹⁸ Results of FDA’s review were inconclusive; unclear whether PDSS caused the deaths, but the possibility that the deaths were due to rapid but delayed entry of the drug into the bloodstream following IM injection could not be excluded.³⁹¹ ³⁹⁸ FDA recommends that clinicians continue to follow the REMS requirements and recommendations in the manufacturer’s prescribing information.³⁹¹ ³⁹⁸ (See Post-Injection Delirium/Sedation Syndrome [PDSS] in Boxed Warning and see Restricted Distribution and also Precautions related to Risk of PDSS under Dosage and Administration.)

Increased Mortality in Geriatric Patients with Dementia-related Psychosis

Increased risk of death with use of either conventional (first-generation) or atypical (second-generation) antipsychotics in geriatric patients with dementia-related psychosis.¹ ²⁶ ¹⁰¹ ³⁸² ³⁹⁹

Antipsychotic agents, including olanzapine, are not approved for the treatment of dementia-related psychosis.¹ ²⁶ ¹⁰¹ ³⁸² ³⁹⁹ (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning, see Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis under Cautions, and also see Dysphagia under Cautions.)

Sensitivity Reactions

Allergic/hypersensitivity reactions (e.g., anaphylactoid reaction, angioedema, pruritus, urticaria, rash) reported.¹ ³¹² ⁴⁰² Discontinue olanzapine if alternative etiology of rash or other allergic manifestation cannot be identified.³¹²

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

DRESS (also known as multiorgan hypersensitivity and hypersensitivity syndrome), a rare but serious dermatologic reaction that can progress to other parts of the body, reported with olanzapine.¹⁹³ ⁴⁰¹ ⁴⁰³ DRESS can be fatal in up to 10% of cases and consists of a combination of ≥3 of the following manifestations: cutaneous reaction (e.g., rash, exfoliative dermatitis), eosinophilia, fever, lymphadenopathy, and ≥1 systemic complications (e.g., hepatitis, myocarditis, pericarditis, pancreatitis, nephritis, pneumonitis).⁴⁰¹

In an FDA review of 23 cases of DRESS, including 1 fatal case, associated with olanzapine use worldwide, median onset of DRESS symptoms was 19 days after initiation of therapy and median olanzapine dosage was 20 mg daily, although DRESS reported at dosages as low as 5 mg daily.⁴⁰¹ The 22 non-fatal cases reported serious outcomes, including 18 that required hospitalization.⁴⁰¹ Complete resolution of symptoms reported in 9 cases after discontinuance of olanzapine; recurrence of symptoms after reinitiation of olanzapine occurred in one case.⁴⁰¹ In the fatal case, the patient was taking multiple other drugs that may have contributed to death.⁴⁰¹

Early recognition of DRESS is essential.⁴⁰¹ If DRESS is suspected, immediately discontinue olanzapine and initiate supportive care.⁴⁰¹ If there is extensive organ involvement, consider corticosteroid therapy.⁴⁰¹ (See Advice to Patients.)

Other Warnings and Precautions

Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis

Increased incidence of adverse cerebrovascular effects (stroke and TIAs), including fatalities, observed in geriatric patients with dementia-related psychosis receiving olanzapine in placebo-controlled studies.¹ ³⁸² Olanzapine is not approved for the treatment of patients with dementia-related psychosis.¹ ³⁸² (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning.)

Suicide

Attendant risk with psychotic illness and bipolar disorder; closely supervise high-risk patients.¹ ³⁸² Prescribe in the smallest quantity consistent with good patient management to reduce the risk of overdosage.¹

Neuroleptic Malignant Syndrome

Neuroleptic malignant syndrome (NMS), a potentially fatal syndrome characterized by hyperpyrexia, muscle rigidity, altered mental status, and autonomic instability, reported with antipsychotic agents, including olanzapine.¹ ²⁶ ¹⁷⁶ ¹⁷⁷ ¹⁷⁸ ¹⁷⁹ ¹⁸⁰ ¹⁸¹ ¹⁸² ¹⁸³ ¹⁸⁴ ¹⁸⁵ ¹⁸⁶ ²⁰¹ ³¹⁵ ³⁸²

Immediately discontinue therapy and initiate supportive and symptomatic therapy if NMS occurs.¹ ³⁸² Careful monitoring recommended if therapy is reinstituted following recovery; the risk that NMS can recur must be considered.¹ ¹⁷⁸ ¹⁷⁹ ¹⁸⁵ ²⁰¹ ³⁸²

Metabolic Changes

Atypical antipsychotic agents are associated with metabolic changes that may increase cardiovascular and cerebrovascular risk (e.g., hyperglycemia, dyslipidemia, weight gain).¹ ³⁸² (See Hyperglycemia and Diabetes Mellitus, see Dyslipidemia, and also see Weight Gain under Cautions.)

Hyperglycemia and Diabetes Mellitus

Hyperglycemia, sometimes severe and associated with ketoacidosis, hyperosmolar coma, or death, reported in patients receiving atypical antipsychotic agents, including olanzapine.¹ ⁴³ ⁴⁴ ⁴⁵ ⁴⁶ ⁴⁷ ⁴⁸ ⁴⁹ ⁵⁰ ⁵¹ ⁵² ⁵³ ⁵⁴ ⁵⁵ ⁵⁶ ⁷⁰ ⁷¹ ⁷² ⁷³ ⁷⁷ ⁹⁵

Closely monitor patients with diabetes mellitus for worsening glycemic control and perform fasting glucose testing at baseline and periodically for patients with risk factors for diabetes (e.g., obesity, family history of diabetes).¹ ⁴⁴ ⁴⁵ ⁴⁶ ⁴⁷ ⁴⁸ ⁴⁹ ⁵⁰ ⁵¹ ⁵² ⁵³ ⁵⁴ ⁵⁵ If manifestations of hyperglycemia occur, perform fasting blood glucose testing.¹ ⁴⁴ ⁴⁵ ⁴⁶ ⁴⁷ ⁴⁸ ⁴⁹ ⁵⁰ ⁵¹ ⁵² ⁵³ ⁵⁴ ⁵⁵

Some patients who developed hyperglycemia while receiving an atypical antipsychotic have required continuance of antidiabetic treatment despite discontinuance of the suspect drug; in other patients, hyperglycemia resolved with discontinuance of the antipsychotic.¹

Dyslipidemia

Undesirable changes in lipid parameters observed with olanzapine use.¹ ³⁸² Clinically important, and sometimes very high (>500 mg/dL), elevations in triglyceride concentrations possible.¹ ³⁸² Modest average increases in total cholesterol concentrations also have occurred.¹

The manufacturers recommend appropriate clinical monitoring, including baseline and periodic follow-up lipid evaluations, in patients receiving the drug.¹ ³⁷³ ³⁸²

Weight Gain

Weight gain reported.¹ ³⁶ ¹²⁹ ¹³⁰ ¹³¹ ¹³² ¹³³ ¹⁴⁰ ²⁴⁷ ²⁵³ ²⁸⁰ ³⁵⁰ ³⁵¹ ³⁶⁹ ³⁷³ ³⁸² In placebo-controlled trials, approximately 22% of adults and 41% of adolescent patients receiving olanzapine monotherapy gained ≥7% of their baseline body weight.¹

Consider potential consequences of weight gain prior to starting olanzapine therapy.¹ ³⁷³ ³⁸² Patients should receive regular monitoring of weight.¹ ³⁷³ ³⁸² (See Pediatric Use under Cautions.)

Tardive Dyskinesia

Tardive dyskinesia, a syndrome of potentially irreversible, involuntary dyskinetic movements, may occur in patients receiving antipsychotic agents.¹

Reserve long-term antipsychotic treatment for patients with chronic illness known to respond to antipsychotic agents, and for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate.¹ In patients requiring chronic treatment, use smallest dosage and shortest duration of treatment producing a satisfactory clinical response; periodically reassess need for continued therapy.¹

APA recommends assessing patients receiving atypical antipsychotic agents for abnormal involuntary movements every 12 months; for patients at increased risk for tardive dyskinesia, assess every 6 months.²⁶ Consider discontinuance of olanzapine if signs and symptoms of tardive dyskinesia occur.¹ However, some patients may require treatment despite the presence of the syndrome.¹

Orthostatic Hypotension

Risk of orthostatic hypotension associated with dizziness, tachycardia, and syncope, particularly early in treatment, because of olanzapine’s α₁-adrenergic blocking activity.¹ Syncope reported in 0.6, 0.3, and 0.1% of patients receiving oral olanzapine, immediate-release IM olanzapine, and extended-release IM olanzapine pamoate, respectively, in clinical studies.¹ ³⁸² May reduce risk of orthostatic hypotension and syncope by initiating oral therapy at a dosage of 5 mg once daily.¹

Hypotension, bradycardia with or without hypotension, tachycardia, and syncope reported with immediate-release IM olanzapine injection.¹

Use oral or IM olanzapine with caution in patients with known cardiovascular disease (e.g., heart failure, history of MI, ischemic heart disease, conduction abnormalities), cerebrovascular disease, and/or conditions that would predispose patients to hypotension (e.g., dehydration, hypovolemia, concomitant antihypertensive therapy).¹ ³⁸²

Risk of clinically important orthostatic hypotension associated with use of maximum recommended IM dosages of immediate-release olanzapine injection (i.e., three 10-mg IM doses given 2–4 hours apart).¹ If drowsiness or dizziness occurs, patients should remain recumbent until examination indicates that they are not experiencing orthostatic hypotension, bradycardia, and/or hypoventilation.¹ Assess patients for orthostatic hypotension prior to administration of any subsequent IM doses.¹ Administration of additional IM doses to patients with clinically significant postural change in BP is not recommended.¹

Use oral or IM olanzapine with caution in patients receiving other drugs that can induce hypotension, bradycardia, or respiratory and CNS depression (e.g., benzodiazepines).¹ ³⁸² (See Specific Drugs under Interactions.)

Falls

May cause somnolence, postural hypotension, and motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries.⁴³⁰

In patients with diseases, conditions, or other drugs that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic therapy and repeat such testing periodically during long-term therapy.⁴³⁰

Leukopenia, Neutropenia, and Agranulocytosis

Leukopenia and neutropenia temporally related to antipsychotic agents, including olanzapine, reported during clinical trial and/or postmarketing experience.¹ ³⁷⁶ ³⁷⁸ ³⁸² Agranulocytosis also reported.¹ ³⁸²

Possible risk factors for leukopenia and neutropenia include preexisting low WBC count and a history of drug-induced leukopenia or neutropenia.¹ ³⁸² Monitor CBC frequently during the first few months of therapy in patients with such risk factors.¹ ³⁸² Discontinue olanzapine at the first sign of a decline in WBC count in the absence of other causative factors.¹ ³⁸²

Carefully monitor patients with clinically important neutropenia for signs and symptoms of infection (e.g., fever) and treat promptly if they occur.¹ ³⁸² Discontinue olanzapine if severe neutropenia (ANC <1000/mm³) occurs; monitor WBC until recovery occurs.¹ ³⁸²

Dysphagia

Esophageal dysmotility and aspiration associated with the use of antipsychotic agents.¹ Aspiration pneumonia is a common cause of morbidity and mortality in geriatric patients, particularly in those with advanced Alzheimer’s dementia.¹ (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning.)

Seizures

Seizures reported in 0.9 and 0.15% of adults receiving oral olanzapine or extended-release IM olanzapine pamoate, respectively.¹ ³⁸²

Use with caution in patients with a history of seizures or conditions known to lower the seizure threshold (e.g., dementia of the Alzheimer’s type); conditions that lower seizure threshold may be more prevalent in patients ≥65 years of age.¹ ²⁰ ²⁴ ¹⁷¹ ¹⁷² ¹⁷⁴ ¹⁷⁵ ³¹⁵ ³⁸²

Cognitive and Motor Impairment

Dose-related somnolence commonly occurs with olanzapine (26% of patients).¹ Sedation occurred in 8% of patients receiving extended-release IM olanzapine pamoate.³⁸²

Judgment, thinking, or motor skills may be impaired.¹ ³⁸² (See Specific Drugs under Interactions and also see Advice to Patients.)

Body Temperature Regulation

Disruption of the body’s ability to reduce core body temperature possible with antipsychotic agents.¹ ³⁸²

Use appropriate caution in patients who will be experiencing conditions that may contribute to an elevation in core body temperature (e.g., strenuous exercise, extreme heat, concomitant use of agents with anticholinergic activity, dehydration).¹ ³⁸²

Hyperprolactinemia

May cause elevated serum prolactin concentrations, which may persist during chronic administration and cause clinical disturbances (e.g., galactorrhea, amenorrhea, gynecomastia, impotence); chronic hyperprolactinemia associated with hypogonadism may lead to decreased bone density.¹ ²⁸¹ ²⁸³ ³⁰⁰ ³⁰¹ ³⁰² (See Pediatric Use under Cautions.)

Olanzapine is considered to be relatively low to moderate among antipsychotic agents in its potential for inducing hyperprolactinemia.²⁶ ²⁸¹ ³⁷⁷

If contemplating olanzapine therapy in a patient with previously detected breast cancer, consider that approximately one-third of human breast cancers are prolactin dependent in vitro.¹

Concomitant Illnesses

Constipation, dry mouth, and tachycardia may occur, possibly related to the drug’s anticholinergic effects; use with caution in patients with clinically important prostatic hypertrophy, angle-closure glaucoma, or history of paralytic ileus or related conditions.¹ ³⁸²

Not adequately evaluated in patients with a recent history of MI or unstable cardiovascular disease.¹ ³⁸² Risk of orthostatic hypotension; use with caution in patients with cardiovascular disease.¹ ³⁸² (See Orthostatic Hypotension under Cautions.)

Phenylketonuria

Orally disintegrating tablets contain aspartame (e.g., NutraSweet), which is metabolized in the GI tract to provide phenylalanine; consult manufacturer’s labeling for specific information regarding phenylalanine content of individual preparations and dosage strengths.¹ ³⁰ ³¹ ³² ³³ ³⁴

Combination Therapy with Lithium, Valproate, or Fluoxetine

Consider cautions, precautions, and contraindications associated with lithium, valproate, or fluoxetine when olanzapine is used in conjunction with these drugs.¹ ³¹²

Possible Prescribing and Dispensing Errors

Ensure accuracy of prescription; similarities in spelling, dosage intervals, and tablet strengths of Zyprexa and Zyrtec (cetirizine hydrochloride, an antihistamine) may result in errors.⁹⁷

Specific Populations

Pregnancy

Category C.¹ ³¹² ³⁸²

Risk for extrapyramidal and/or withdrawal symptoms (e.g., agitation, hypertonia, hypotonia, tardive dyskinetic-like symptoms, tremor, somnolence, respiratory distress, feeding disorder) in neonates exposed to antipsychotic agents during the third trimester; monitor neonates exhibiting such symptoms.¹ ³¹² ³⁷⁹ ³⁸⁰ ³⁸¹ ³⁸² Symptoms were self-limiting in some neonates but varied in severity; some infants required intensive support and prolonged hospitalization.¹ ³¹² ³⁷⁹ ³⁸⁰ ³⁸¹ ³⁸²

Lactation

Distributed into milk.¹ ¹¹⁰ ¹¹¹ ¹¹² ¹¹³ ³¹⁹ Women receiving olanzapine should not breast-feed.¹

Pediatric Use

Safety and efficacy of oral olanzapine for the treatment of schizophrenia or manic or mixed episodes associated with bipolar I disorder established in short-term clinical trials in adolescents (13–17 years of age).¹ ³⁶⁹ ³⁷⁰ The recommended initial dosage for adolescents is lower than that for adults (see Dosage under Dosage and Administration).¹ Safety and efficacy of oral olanzapine for the treatment of schizophrenia or manic or mixed episodes associated with bipolar I disorder not established in pediatric patients <13 years of age.¹ ³⁵ Compared with adults in clinical trials, adolescents were likely to gain more weight, experience increased sedation, and have greater increases in serum concentrations of total cholesterol, triglycerides, LDL-cholesterol, prolactin, and hepatic aminotransferases.¹ ³⁶⁹ ³⁷⁰ ³⁷³

When deciding among the alternative treatments available for adolescents with schizophrenia or bipolar disorder, consider the increased potential for weight gain and dyslipidemia with olanzapine in adolescents as compared with adults.¹ ³⁷³ Also consider the potential long-term risks when prescribing olanzapine to adolescents; in many cases, this may lead to consideration of other drugs first in such patients.¹ ³⁷³

Initiate drug therapy for pediatric schizophrenia and bipolar I disorder only after performing a thorough diagnostic evaluation and carefully considering risks associated with medication treatment.¹ ³⁷³ Medication treatment should only be part of a total treatment program that often includes psychological, educational, and social interventions.¹ ³⁷³

Safety and efficacy of oral olanzapine in combination with fluoxetine for the treatment of acute depressive episodes associated with bipolar disorder not established in pediatric patients <10 years of age.¹ ³¹²

Safety and efficacy of oral olanzapine in combination with fluoxetine for the treatment of treatment-resistant depression not established in patients <18 years of age.¹ ³¹²

Safety and efficacy of short-acting IM olanzapine not established in patients <18 years of age.¹

Safety and efficacy of extended-release IM olanzapine pamoate not established in patients <18 years of age.³⁸²

Geriatric Use

Safety of oral olanzapine in patients ≥65 years of age with schizophrenia does not appear to differ from that in younger adults with schizophrenia; however, tolerability profile of olanzapine in geriatric patients with dementia-related psychosis may differ from that in younger patients with schizophrenia.¹

The manufacturer states that the presence of factors that might decrease the clearance of or increase the pharmacodynamic response to olanzapine should lead to consideration of a lower initial dosage in geriatric patients.¹ ³¹² ³⁸² (See Special Populations under Dosage and Administration.)

Geriatric patients with dementia-related psychosis treated with antipsychotic agents, including olanzapine, are at an increased risk of death;¹ ²⁶ ¹⁰¹ ³⁸² ³⁹⁹ increased incidence of adverse cerebrovascular events also observed in geriatric patients with dementia-related psychosis receiving oral olanzapine.¹ Olanzapine is not approved for the treatment of patients with dementia-related psychosis.¹ ³⁸² (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning, see Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis under Cautions, and also see Dysphagia under Cautions.)

Clinical studies of olanzapine in combination with fluoxetine did not include sufficient numbers of patients ≥65 years of age to determine whether they respond differently than younger patients.¹ ³¹²

Clinical studies of extended-release IM olanzapine pamoate did not include sufficient numbers of patients ≥65 years of age to determine whether they respond differently than younger patients.³⁸²

Common Adverse Effects

Oral olanzapine therapy in adults with schizophrenia: Postural hypotension, constipation, weight gain, dizziness, personality disorder, akathisia.¹

Oral olanzapine therapy in adolescents with schizophrenia: Sedation, weight gain, headache, increased appetite, dizziness, abdominal pain, pain in the extremities, fatigue, dry mouth.¹

Oral olanzapine therapy for manic or mixed episodes associated with bipolar disorder (as monotherapy) in adults: Asthenia, dry mouth, constipation, increased appetite, somnolence, dizziness, tremor.¹

Oral olanzapine therapy for manic or mixed episodes associated with bipolar disorder (as monotherapy) in adolescents: Sedation, weight gain, increased appetite, headache, fatigue, dizziness, dry mouth, abdominal pain, pain in the extremities.¹

Oral olanzapine therapy for manic or mixed episodes associated with bipolar disorder (as adjunctive therapy with lithium or valproate) in adults: Dry mouth, weight gain, increased appetite, dizziness, back pain, constipation, speech disorder, increased salivation, amnesia, paresthesia.¹

Olanzapine IM (short-acting injection) for agitation associated with schizophrenia or bipolar mania in adults: Somnolence.¹

Olanzapine pamoate IM (long-acting) therapy in adults: Headache, sedation, weight gain, cough, diarrhea, back pain, nausea, somnolence, dry mouth, nasopharyngitis, increased appetite, vomiting.³⁸²

Drug Interactions

Direct glucuronidation and CYP-mediated oxidation are main metabolic pathways.¹ ¹¹⁶ In vitro studies suggest that CYP1A2 and CYP2D6 and the flavin-containing monooxygenase system are involved in oxidation; however, CYP2D6-mediated oxidation appears to be a minor pathway.¹ ¹¹⁶

Appears to have little potential to inhibit CYP isoenzymes 1A2, 2C9, 2C19, 2D6, and 3A.¹ ¹¹⁶

Although metabolized by multiple enzyme systems, induction or inhibition of a single enzyme may appreciably alter drug clearance.¹ ¹¹⁶

Drugs Affecting Hepatic Microsomal Enzymes

CYP1A2 or glucuronyl transferase enzyme inhibitors and inducers: Potential pharmacokinetic interaction (altered olanzapine metabolism).¹ ¹¹⁶

Drugs Metabolized by Hepatic Microsomal Enzymes

Inhibitors of CYP 1A2, 2C9, 2C19, 2D6, or 3A: Clinically important pharmacokinetic interactions unlikely.¹ ¹¹⁶

Specific Drugs

Drug	Interaction	Comment
Alcohol	Pharmacokinetic interaction unlikely¹ ¹¹⁶ ³⁸² Potential additive CNS effects; alcohol potentiates orthostatic hypotension observed with olanzapine¹ ³⁸²	Advise patients to avoid alcohol ¹ ³⁸²
Antacids (aluminum- and magnesium-containing)	Pharmacokinetic interaction unlikely¹ ¹¹⁶
Anticholinergic agents	Possible disruption of body temperature regulation¹ ³⁸²	Use with caution ¹ ³⁸²
Benzodiazepines (parenteral) (e.g., lorazepam)	Potential additive CNS and cardiovascular effects (excessive sedation and cardiorespiratory depression) during concurrent parenteral administration¹ ³⁸² Increased somnolence during concurrent parenteral administration of short-acting olanzapine and lorazepam; no effect on pharmacokinetics of either drug¹	Concurrent use of short-acting IM olanzapine with parenteral benzodiazepines not recommended¹ If administered concurrently, carefully evaluate for excessive sedation and cardiorespiratory depression¹ ³⁸²
Biperiden	Pharmacokinetic interaction unlikely¹ ¹¹⁶
Carbamazepine	Carbamazepine (200 mg twice daily) increased clearance of olanzapine (single 10-mg dose) by about 50%;¹ ¹¹⁶ effect may be greater with higher carbamazepine dosages¹ ¹¹⁶	Consider increase in olanzapine dosage during concurrent use¹ ¹¹⁶
Charcoal	Decreased peak plasma concentrations and AUC of oral olanzapine¹ ¹¹⁶	Charcoal may be useful in treatment of olanzapine overdose¹ ¹¹⁶
Cimetidine	Pharmacokinetic interaction unlikely¹ ¹¹⁶
CNS agents	Potential additive CNS effects¹	Use with caution¹
Desipramine	Pharmacokinetic interaction unlikely¹
Diazepam (oral)	Potential additive CNS and orthostatic hypotension effects; no effect on diazepam pharmacokinetics¹	Use with caution¹
Dopamine agonists	Potential antagonistic effects¹
Fluoxetine	Small increase in peak olanzapine concentrations and small decrease in olanzapine clearance¹ ¹¹⁶ ³¹² ³³⁰	Not considered clinically important; dosage modification not routinely recommended¹ ¹¹⁶ ³¹² ³³⁰
Fluvoxamine	Decreased clearance and increased peak concentrations of olanzapine ¹ ¹⁵¹ ¹⁵² ¹⁵³ ¹⁵⁵ ¹⁵⁶	Use with caution; consider lower olanzapine dosage¹ ¹⁵¹ ¹⁵² ¹⁵³ ¹⁵⁶ Consider monitoring plasma olanzapine concentrations¹⁵¹ ¹⁵² ¹⁵³ ¹⁵⁶
Hypotensive agents	Additive hypotensive effects¹	Use with caution¹
Imipramine	Pharmacokinetic interaction unlikely¹ ²⁸²
Lamotrigine	No substantial change in olanzapine or lamotrigine pharmacokinetics;²⁸⁴ ³³¹ however, time to reach peak lamotrigine concentrations may be substantially prolonged³³¹ Mild sedative effects reported²⁸⁴ ³³¹	Routine dosage adjustment not necessary; however, lamotrigine dosage adjustment for therapeutic reasons may be necessary in some patients when initiating or discontinuing olanzapine therapy²⁸⁴ Careful monitoring of patients receiving high dosages of olanzapine and lamotrigine recommended by some clinicians²⁸⁴
Levodopa	Potential antagonistic effects¹
Lithium	Pharmacokinetic interaction unlikely¹ ¹¹⁶ Although combined olanzapine and lithium therapy generally well tolerated,¹ ⁴¹ apparent lithium toxicity and adverse extrapyramidal effects reported rarely³⁴⁸	No dosage adjustment of lithium necessary during concomitant administration¹
Omeprazole	Possible increase in olanzapine clearance¹	Consider increase in olanzapine dosage during concurrent use¹
Rifampin	Possible increase in olanzapine clearance¹ ¹¹⁶	Consider increase in olanzapine dosage during concurrent use¹ ¹¹⁶
Sertraline	Sertraline does not appear to substantially affect olanzapine pharmacokinetics¹⁵⁶
Smoking	Olanzapine clearance approximately 40% higher in smokers; olanzapine concentrations generally lower in smokers compared with nonsmokers¹ ¹³⁴ ¹³⁵ ¹⁴¹ ¹⁴² ¹⁴⁴	Manufacturer states that routine dosage adjustment is not recommended in smokers¹ Some clinicians recommend monitoring patient’s smoking consumption and considering olanzapine dosage adjustment in patients who have reduced or increased their smoking and/or are not responding adequately or are experiencing dose-related adverse reactions to the drug¹³⁴ ¹³⁸ Monitoring olanzapine concentrations may be helpful in patients who smoke and have other factors associated with substantial alterations in olanzapine metabolism (e.g., geriatric patients, women, concurrent fluvoxamine use)¹⁴¹
Theophylline	Pharmacokinetic interaction unlikely¹ ¹¹⁶
Valproic acid	Clinically important pharmacokinetic interaction unlikely,¹ although substantially decreased olanzapine concentrations reported in several olanzapine-treated patients following initiation of valproate³⁴⁹	Routine dosage adjustment of valproate not necessary during concomitant administration¹
Warfarin	Pharmacokinetic interaction unlikely¹ ¹¹⁶

Olanzapine Pharmacokinetics

Absorption

Bioavailability

Well absorbed after oral administration, with peak plasma concentrations attained in approximately 6 hours (range: 5–8 hours).¹ ²⁹⁰ About 40% of oral dose is metabolized before reaching systemic circulation.¹

Steady-state concentrations achieved after approximately 7 days of continuous oral dosing and are approximately twice those observed following single-dose administration.¹ ¹¹⁶ ²⁹⁰

Exhibits linear and dose-proportional pharmacokinetics when given orally within the clinical dosage range.¹ ¹¹⁶ ¹⁴³ ²⁹⁰

Conventional and orally disintegrating olanzapine tablets are bioequivalent.¹ ¹¹⁵

Fixed-combination olanzapine/fluoxetine capsules: Pharmacokinetics expected to resemble those of the individual components.³¹² Olanzapine pharmacokinetics slightly altered, but effects not clinically important.³¹² (See Specific Drugs under Interactions.)

Short-acting IM olanzapine (Zyprexa IntraMuscular): Rapidly absorbed following IM administration, with peak plasma concentrations occurring within 15–45 minutes.¹ ³⁸² Peak olanzapine concentrations after 5-mg IM dose average about 5 times higher than those following a 5-mg oral dose.¹ AUCs are similar following oral and IM administration.¹ Exhibits linear pharmacokinetics when given IM within the clinical dosage range.¹ Onset of antipsychotic action evident within 24 hours after IM administration, but may occur within 2 hours.²⁰⁷

Extended-release IM olanzapine (Zyprexa Relprevv): Following deep IM gluteal administration, slow dissolution of the pamoate ester (which is practically insoluble) results in prolonged plasma olanzapine concentrations over a period of weeks to months.³⁸² IM injection every 2 or 4 weeks provides plasma olanzapine concentrations similar to those achieved with daily oral dosing.³⁸² Steady-state olanzapine concentrations achieved with IM dosages of 150–405 mg every 2 or 4 weeks are within the range achieved with oral olanzapine dosages of 5–20 mg daily.³⁸² Plasma concentrations generally reach a peak within the first week following each injection.³⁸²

Food

Food does not affect rate or extent of oral absorption.¹ ²⁹⁰

Distribution

Extent

Extensively distributed throughout the body.¹ ¹⁴⁶ ²⁹⁰

Olanzapine and its glucuronide metabolite cross the placenta.¹¹⁴ ³⁸¹ Distributed into milk in humans;¹ ¹¹⁰ ¹¹¹ ¹¹² ¹¹³ ³¹⁹ mean infant dose at steady state estimated to be about 1.8% of maternal dose.¹

Plasma Protein Binding

93% (mainly to albumin and α₁-acid glycoprotein).¹ ¹³⁹ ²⁹⁰

Elimination

Metabolism

Metabolized to inactive metabolites, principally via direct glucuronidation and oxidation via CYP isoenzymes (mainly CYP1A2) and the flavin-containing monooxygenase system, with minor contribution of CYP2D6.¹ ¹¹⁶

Elimination Route

Excreted in urine (57%) and feces (30%); 7% of dose is excreted in urine as unchanged drug.¹

Half-life

Oral administration: 21–54 hours.¹ ¹¹⁶ ¹³⁹

IM administration of short-acting olanzapine injection: Half-life similar to that observed with oral administration.¹

IM administration of extended-release olanzapine pamoate injection: Approximately 30 days.³⁸² Exposure to olanzapine may persist for months after a single long-acting IM injection.³⁸²

Special Populations

In patients with severe renal impairment, pharmacokinetics were similar to healthy individuals.¹

Not appreciably removed by hemodialysis, probably due to large volume of distribution and extensive protein binding.¹ ¹¹⁶ ¹¹⁹ ¹⁴⁶

Although hepatic impairment may be expected to reduce clearance, a study in patients with clinically important cirrhosis (Child-Pugh class A and B) revealed little effect on the pharmacokinetics of olanzapine.¹

In children and adolescents 10–18 years of age treated with oral olanzapine for schizophrenia, clearance at steady state was approximately half of that in adults but was similar to that reported in nonsmoking male and female schizophrenic patients.¹ ¹¹⁶ ¹⁴⁸ ²⁹⁰ Elimination half-life averaged 37.2 hours in this study.¹⁴⁸

In geriatric patients, the mean elimination half-life of orally administered olanzapine was about 1.5 times that of younger patients.¹

In women, clearance of olanzapine is approximately 30% lower than in men; there were no apparent differences between men and women in efficacy or adverse effects.¹

In smokers, olanzapine clearance is about 40% higher than in nonsmokers, although dosage adjustment is not recommended.¹

Combined effects of age, smoking, and gender may contribute to substantial pharmacokinetic differences in populations.¹

Stability

Storage

Oral

Conventional and Orally Disintegrating Tablets

20–25°C (may be exposed to 15–30°C).¹ Store orally disintegrating tablets in their original sealed blister.¹ Protect from light and moisture.¹

Fixed-combination (with Fluoxetine) Capsules

Tight containers at 25°C (may be exposed to 15–30°C).³¹² Protect from moisture.³¹²

Parenteral

Immediate-release Olanzapine Powder for IM Injection (e.g., Zyprexa IntraMuscular)

20–25°C (may be exposed to 15–30°C).¹ Protect from light and avoid freezing.¹

Reconstituted solution may be stored for up to 1 hour at 20–25°C, if necessary; after 1 hour, discard any unused portion.¹

Extended-release Olanzapine Pamoate Powder for IM Injection (Zyprexa Relprevv)

Store at room temperature (not to exceed 30°C).³⁸²

Reconstituted suspension may be stored for up to 24 hours at room temperature; once withdrawn into syringe for administration, use immediately.³⁸²

Compatibility

Parenteral

Drug Compatibility

Admixture Compatibility1
Incompatible
Diazepam
Haloperidol
Lorazepam

Actions

Exact mechanism of antipsychotic action has not been fully elucidated; may involve antagonism at serotonin type 2 (5-hydroxytryptamine [5-HT_2A, 5-HT_2C]), type 3 (5-HT₃), type 6 (5-HT₆),⁴ ⁸ ¹⁹ ²⁰ ²¹ and dopamine receptors.¹ ⁴ ⁶ ⁷ ¹⁶ ¹⁷ ¹⁸ ¹⁹ ²⁰ ²¹ ²² ¹⁶⁴ ²⁸⁸ ²⁸⁹ ²⁹⁰ ³¹⁵ ³³³
Exact mechanism(s) in treatment of acute manic or mixed episodes associated with bipolar disorder not known;¹ ³⁴⁷ antagonism and downregulation of 5-HT_2A receptors may play a role.³⁴⁷ In addition, mood-stabilizing action may be caused at least in part by antagonism of dopamine type 2 (D₂) receptors.³⁴⁷
Although not clearly established, efficacy of IM olanzapine in acute agitation appears to be due, at least in part, to its distinct calming effects rather than solely to nonspecific sedation.¹⁰⁴
Although precise mechanism not known, antiemetic efficacy may be due, at least in part, to olanzapine’s inhibitory activity at multiple dopaminergic and serotonergic receptors, particularly the D₂, 5-HT_2C, and 5-HT₃ receptors that may be involved in nausea and vomiting.⁴²⁶ ⁴²⁷ ⁴²⁸
Antagonism at other receptors (e.g., α₁-adrenergic receptors, muscarinic receptors, histamine H₁ receptors) may contribute to other therapeutic and adverse effects (e.g., orthostatic hypotension, anticholinergic effects, sedative effects) observed with olanzapine.¹ ² ⁶ ⁷ ¹⁶ ¹⁷ ²⁰
Possesses little or no affinity for β-adrenergic, γ-aminobutyric acid (GABA), or benzodiazepine receptors.¹ ¹⁶ ²⁰

Advice to Patients

Importance of informing patients, their families, and caregivers about the potential benefits and risks associated with olanzapine therapy, counseling them about its appropriate use, and advising them to read the patient information (medication guide) for the drug.¹ ³¹² ³⁸²
Importance of informing patients receiving extended-release olanzapine pamoate (Zyprexa Relprevv) of the risk of PDSS each time they receive an injection.³⁸² ³⁹⁸ Advise patients that they should be observed at a healthcare facility for at least 3 hours following each IM injection, must be accompanied to their destination upon leaving the facility, and should not drive or operate heavy machinery for the remainder of the day after each injection.³⁸² Importance of providing a copy of the medication guide for patients to read each time they receive an injection of extended-release olanzapine pamoate.³⁸² ³⁹⁸ Advise patients and caregivers to immediately notify the clinician if symptoms of PDSS occur (e.g., CNS depression ranging from mild sedation to coma, dizziness, confusion or disorientation, slurred speech, altered gait, difficulty ambulating, weakness, agitation, extrapyramidal symptoms, hypertension, convulsions).³⁸²
Importance of advising patients and caregivers that geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death¹ ³¹² ³⁷⁴ ³⁸⁰ ³⁸² and that such patients treated with olanzapine had a substantially higher incidence of adverse cerebrovascular events (e.g., stroke, TIA) compared with placebo.¹ ³¹² ³⁷⁴ ³⁸⁰ ³⁸² Importance of informing patients and caregivers that olanzapine is not approved for treating geriatric patients with dementia-related psychosis.¹ ³¹² ³⁷⁴ ³⁸²
Risk of NMS, which can cause high fever, stiff muscles, sweating, fast or irregular heart beat, change in BP, confusion, and kidney damage.¹ ³⁸²
Risk of drug reaction with eosinophilia and systemic symptoms (DRESS).⁴⁰¹ Importance of advising patients to seek immediate medical care if symptoms of DRESS, including rash, fever, facial swelling, and/or lymphadenopathy, occur.⁴⁰¹
Potential risk of hyperglycemia-associated adverse reactions; importance of regular monitoring for worsening of glucose control.¹ ³⁸² Advise diabetic patients to follow their clinician’s instructions regarding the frequency of blood glucose monitoring.¹ ³⁸²
Risk of dyslipidemia.¹ ³⁸² Importance of regular lipid profile monitoring.¹ ³⁸²
Risk of weight gain.¹ ³⁸² Importance of monitoring body weight during therapy.¹ ³⁸²
Risk of orthostatic hypotension, especially during initial oral dosage titration and when using concomitant drugs that may increase the orthostatic effect of olanzapine (e.g., diazepam, alcohol).¹ ³⁸² Advise patients to change positions carefully to help prevent orthostatic hypotension, and to lie down if they feel dizzy or faint, until they feel better.¹ ³⁸² Advise patients to notify their clinician if they experience signs and symptoms of orthostatic hypotension, including dizziness, fast or slow heart beat, or fainting.¹ ³⁸²
Risk of somnolence/sedation and impairment of judgment, thinking, or motor skills; advise patients to exercise caution when driving or operating hazardous machinery until they gain experience with the drug’s effects.¹ ³⁸² In addition, because of the risk of PDSS, advise patients receiving extended-release olanzapine pamoate injection that they should not drive or operate heavy machinery for the remainder of the day after each injection.³⁸²
Importance of avoiding alcohol during olanzapine therapy.¹ ³⁸²
Importance of informing adolescent patients and/or their caregivers that adolescent patients receiving oral olanzapine are likely to gain more weight, experience increased sedation, and have greater increases in serum concentrations of total cholesterol, triglycerides, LDL-cholesterol, prolactin, and hepatic aminotransferases compared with adults; advise such patients about the potential long-term risks associated with olanzapine therapy and that the risks may lead them to consider other drugs first.¹
Importance of avoiding overheating or dehydration.¹ ³⁸² Advise patients to immediately notify their clinician if they become severely ill and have any symptoms of dehydration (e.g., sweating too much or not at all, dry mouth, feeling very hot or thirsty, unable to produce urine).¹ ³⁸²
Importance of informing patients with phenylketonuria that olanzapine orally disintegrating tablets contain aspartame.¹ ³⁰ ³¹ ³² ³³ ³⁴
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs and dietary or herbal supplements, as well as any concomitant illnesses (e.g., diabetes mellitus, seizures, dementia, cardiovascular or cerebrovascular disease).¹ ³¹² ³⁸²
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹ ³¹² ³⁸¹ ³⁸² Importance of clinicians informing patients about the benefits and risks of taking antipsychotics during pregnancy (see Pregnancy under Cautions).¹ ³¹² ³⁸¹ ³⁸² Importance of advising patients not to stop taking olanzapine if they become pregnant without consulting their clinician; abruptly discontinuing antipsychotic agents may cause complications.³⁸¹ Importance of advising patients not to breast-feed during olanzapine therapy.¹ ³¹² ³⁸²
Importance of informing patients of other important precautionary information.¹ ³¹² ³⁸² (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

Long-acting IM olanzapine pamoate (Zyprexa Relprevv) is available only through a restricted distribution program.³⁸² (See Restricted Distribution under Dosage and Administration.)

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

OLANZapine
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Oral	Tablets, film-coated	2.5 mg*	ZyPREXA	Lilly
		5 mg*	ZyPREXA	Lilly
		7.5 mg*	ZyPREXA	Lilly
		10 mg*	ZyPREXA	Lilly
		15 mg*	ZyPREXA	Lilly
		20 mg*	ZyPREXA	Lilly
	Tablets, orally disintegrating	5 mg*	ZyPREXA Zydis	Lilly
		10 mg*	ZyPREXA Zydis	Lilly
		15 mg*	ZyPREXA Zydis	Lilly
		20 mg*	ZyPREXA Zydis	Lilly
Parenteral	For injection, for IM use only	10 mg*	ZyPREXA IntraMuscular	Lilly

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

OLANZapine Combinations
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Oral	Capsules	3 mg with Fluoxetine Hydrochloride 25 mg (of fluoxetine)*	Symbyax	Lilly
		6 mg with Fluoxetine Hydrochloride 25 mg (of fluoxetine)*	Symbyax	Lilly
		6 mg with Fluoxetine Hydrochloride 50 mg (of fluoxetine)*	Symbyax	Lilly
		12 mg with Fluoxetine Hydrochloride 25 mg (of fluoxetine)*	Symbyax	Lilly
		12 mg with Fluoxetine Hydrochloride 50 mg (of fluoxetine)*	Symbyax	Lilly

OLANZapine Pamoate
Routes	Dosage Forms	Strengths	Brand Names	Manufacturer
Parenteral	For injectable suspension, extended-release, for IM use only	210 mg (of olanzapine)	ZyPREXA Relprevv (available as a convenience kit containing single-use vial, needles, syringe, and diluent)	Lilly
		300 mg (of olanzapine)	ZyPREXA Relprevv (available as a convenience kit containing single-use vial, needles, syringe, and diluent)	Lilly
		405 mg (of olanzapine)	ZyPREXA Relprevv (available as a convenience kit containing single-use vial, needles, syringe, and diluent)	Lilly

† Off-label: Use is not currently included in the labeling approved by the US Food and Drug Administration.

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355. Lilly, Indianapolis, IN: Personal communication.

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390. Teva. Olanzapine orally disintegrating tablets prescribing information. Sellersville, PA: 2011 Sep.

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Acute Agitation associated with Schizophrenia

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Bipolar Disorder

Manic or Mixed Episodes: Monotherapy

Acute Depressive Episodes

Adults

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Acute Agitation associated with Schizophrenia

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Tardive Dyskinesia