combinationolanzapine/samidorphan (Lybalvi) for the treatment ofschizophrenia andbipolar I disorder. Lybalvi suppresses the metabolic side effect of olanzapine. More precisely, olanzapine produces weight gain of about 9 kg (20 pounds) in the short-term, which typically increases to around 23–45 kg (50–100 pounds) following long-term use. In contrast, Lybalvi only triggers roughly 5 kg (11 pounds) before subsiding.[22]
In the United Kingdom and Australia, it is approved for schizophrenia, moderate to severe manic episodes, alone, or in combination with lithium or valproate and the short-term treatment of acute manic episodes associated with bipolar I disorder.[3][23]
Olanzapine is also used off-label for the treatment of chemotherapy-induced nausea and vomiting.[13]
The first-line psychiatric treatment for schizophrenia is antipsychotic medication.[24] Olanzapine appears to be effective in reducing symptoms of schizophrenia, treating acute exacerbations, and treating early-onset schizophrenia.[25][26][27][28] The usefulness of maintenance therapy, however, is difficult to determine, as more than half of people in trials quit before the 6-week completion date.[29] Treatment with olanzapine (likeclozapine) may result in increasedweight gain and increased glucose and cholesterol levels when compared to most other second-generation antipsychotic drugs used to treat schizophrenia.[26][30]
Olanzapine is recommended by theNational Institute for Health and Care Excellence as a first-line therapy for the treatment of acute mania in bipolar disorder.[31] Other recommended first-line treatments arearipiprazole,haloperidol,quetiapine, andrisperidone.[32] It is recommended in combination withfluoxetine as a first-line therapy for acute bipolar depression, and as a second-line treatment by itself for the maintenance treatment of bipolar disorder.[31]
The Network for Mood and Anxiety Treatments recommends olanzapine as a first-line maintenance treatment for bipolar disorder and the combination of olanzapine with fluoxetine as a second-line treatment for bipolar depression.[33]
A review on the efficacy of olanzapine as maintenance therapy in people with bipolar disorder was published in 2006.[34] A 2014 meta-analysis concluded that olanzapine with fluoxetine was the most effective among nine treatments for bipolar depression included in the analysis.[35]
Olanzapine is associated with the highest placental exposure of any atypical antipsychotic.[36] Despite this, the available evidence suggests it is safe during pregnancy, although the evidence is insufficiently strong to say anything with a high degree of confidence.[36] Olanzapine is associated with weight gain, which according to recent studies, may put olanzapine-treated patients' offspring at a heightened risk forneural tube defects (e.g.spina bifida).[37][38] Breastfeeding in women taking olanzapine is advised against because olanzapine is secreted in breast milk, with one study finding that the exposure to the infant is about 1.8% that of the mother.[10]
Citing an increased risk ofstroke, in 2004, theCommittee on the Safety of Medicines in the UK issued a warning that olanzapine and risperidone, both atypical antipsychotic medications, should not be given to elderly patients with dementia. In the U.S., olanzapine comes with ablack box warning for increased risk of death in elderly patients. It is not approved for use in patients with dementia-related psychosis.[39] A BBC investigation in June 2008 found that this advice was being widely ignored by British doctors.[40] Evidence suggested that the elderly are more likely to experience weight gain on olanzapine compared toaripiprazole andrisperidone.[41]
The principal side effect of olanzapine isweight gain, which may be profound in some cases and/or associated with derangement in blood-lipid and blood-sugar profiles (see sectionmetabolic effects). A 2013 meta-analysis of the efficacy and tolerance of 15 antipsychotic drugs (APDs) found that it had the highest propensity for causing weight gain out of the 15 APDs compared with an SMD of 0.74.[25] Extrapyramidal side effects, although potentially serious, are infrequent to rare from olanzapine,[42] but may include tremors and muscle rigidity.
Although olanzapine causes an early dose-related rise in prolactin, this is less frequent and less marked than that seen with haloperidol, and is usually transient. A rise inprolactin is seen in about half of patients on olanzapine compared to over 90% of those takingrisperidone, and enduring increases were less frequent in those taking olanzapine.[43]
Several patient groups are at a heightened risk of side effects from olanzapine and antipsychotics in general. Olanzapine may produce nontrivialhigh blood sugar in people withdiabetes mellitus. Likewise, the elderly are at a greater risk of falls and accidental injury. Young males appear to be at heightened risk ofdystonic reactions, although these are relatively rare with olanzapine. Most antipsychotics, including olanzapine, may disrupt the body's natural thermoregulatory systems, thus permitting excursions to dangerous levels when certain situations (exposure to heat, strenuous exercise) occur.[10][11][45][4][3]
The USFood and Drug Administration (FDA) requires atypical antipsychotics to include a warning about the risk of developinghyperglycemia anddiabetes, both of which are factors in themetabolic syndrome. These effects may be related to the drugs' ability to induce weight gain, although some reports have been made of metabolic changes in the absence of weight gain.[47][48] Studies have indicated that olanzapine carries a greater risk of causing and exacerbating diabetes than another commonly prescribed atypical antipsychotic, risperidone. Of all the atypical antipsychotics, olanzapine is the most likely to induce significant weight gain based on various measures.[49][50][51][52][53] The effect is dose dependent in humans[54] and animal models of olanzapine-induced metabolic side effects. There are some case reports of olanzapine-induceddiabetic ketoacidosis.[55] Olanzapine may decreaseinsulin sensitivity,[56][57] though one 3-week study seems to refute this.[58] It may also increasetriglyceride levels.[50]
Despite weight gain, a large multicenter, randomizedNational Institute of Mental Health study found that olanzapine was better at controlling symptoms because patients were more likely to remain on olanzapine than the other drugs.[59] One small, open-label, nonrandomized study suggests that taking olanzapine by orally dissolving tablets may induce less weight gain,[60] but this has not been substantiated in a blinded experimental setting.
Postinjection delirium/sedation syndrome (PDSS) is a rare syndrome that is specific to the long-acting injectable formulation of olanzapine, olanzapinepamoate.[61] The incidence of PDSS with olanzapine pamoate is estimated to be 0.07% of administrations, and is unique among other second-generation, long-acting antipsychotics (e.g.paliperidone palmitate), which do not appear to carry the same risk.[61] PDSS is characterized by symptoms ofdelirium (e.g. confusion,difficulty speaking, anduncoordinated movements) and sedation.[61] Most people with PDSS exhibit both delirium and sedation (83%).[61] Although less specific to PDSS, a majority of cases (67%) involved a feeling ofgeneral discomfort.[61] PDSS may occur due to accidental injection and absorption of olanzapine pamoate into the bloodstream, where it can act more rapidly, as opposed to slowly distributing out from muscle tissue.[61] Using the proper, intramuscular-injection technique for olanzapine pamoate helps to decrease the risk of PDSS, though it does not eliminate it entirely.[61] This is why the FDA advises that people who are injected with olanzapine pamoate be watched for 3 hours after administration, in the event that PDSS occurs.[61]
Olanzapine has demonstrated carcinogenic effects in multiple studies when exposed chronically to female mice and rats, but not male mice and rats. The tumors found were in either the liver or mammary glands of the animals.[62]
TheBritish National Formulary recommends a gradual withdrawal whendiscontinuing antipsychotics to avoid acute withdrawal syndrome or rapid relapse.[63] Symptoms of withdrawal commonly include nausea, vomiting, and loss of appetite.[64] Other symptoms may include restlessness, increased sweating, and trouble sleeping.[64] Less commonly,vertigo, numbness, or muscle pains may occur.[64] Symptoms generally resolve after a short time.[64]
Tentative evidence indicates that discontinuation of antipsychotics can result in psychosis, as a temporary withdrawal symptom.[65] It may also result in reoccurrence of the condition that is being treated.[66] Rarely, tardive dyskinesia can occur when the medication is stopped.[64]
Symptoms of an overdose includetachycardia,agitation,dysarthria, decreased consciousness, and coma. Death has been reported after an acute overdose of 450 mg, but also survival after an acute overdose of 2000 mg.[67] Fatalities generally have occurred with olanzapine plasma concentrations greater than 1000 ng/mLpost mortem, with concentrations up to 5200 ng/mL recorded (though this might represent confounding by dead tissue, which may release olanzapine into the blood upon death).[68] No specific antidote for olanzapine overdose is known, and even physicians are recommended to call a certifiedpoison control center for information on the treatment of such a case.[67]Olanzapine is considered moderately toxic in overdose, more toxic than quetiapine, aripiprazole, and theSSRIs, and less toxic than themonoamine oxidase inhibitors andtricyclic antidepressants.[36]
Drugs or agents that increase the activity of the enzymeCYP1A2, notably tobacco smoke, may significantly increase hepatic first-pass clearance of olanzapine; conversely, drugs that inhibit CYP1A2 activity (examples:ciprofloxacin,fluvoxamine) may reduce olanzapine clearance.[69]Carbamazepine, a known enzyme inducer, has decreased the concentration/dose ratio of olanzapine by 33% compared to olanzapine alone.[68] Another enzyme inducer,ritonavir, has also been shown to decrease the body's exposure to olanzapine, due to its induction of the enzymes CYP1A2 anduridine 5'-diphospho-glucuronosyltransferase (UGT).[68]Probenecid increases the total exposure (area under the curve) andmaximum plasma concentration of olanzapine.[68] Although olanzapine's metabolism includes the minor metabolic pathway ofCYP2D6, the presence of the CYP2D6 inhibitorfluoxetine does not have a clinically significant effect on olanzapine's clearance.[68]
Values are Ki (nM). The smaller the value, the more strongly the drug binds to the site. All data are for human cloned proteins, except H3 (guinea pig), σ1 (guinea pig), opioid (rodent),NMDA/PCP (rat),VDCC, andVGSC.[72]
Olanzapine was first discovered while searching for a chemical analog ofclozapine that would not require hematological monitoring. Investigation on a series of thiophene isosteres on 1 of the phenyl rings in clozapine, athienobenzodiazepine analog (olanzapine) was discovered.[90]
In one studyD2 receptor occupancy was 60% with low-dose olanzapine (5 mg/day) and occupancy with high dose at 83% (20 mg/day).[91] In the usual clinical dose range of 10–20 mg/day,D2 receptor occupancy varied from 71% to 80%.[92]
Olanzapine occupancy at5-HT2A receptor are high at all doses (5 mg to 20 mg). It is reported that 5 mg dose of olanzapine produced a mean occupancy of 85% at 5 mg, 88% at 10 mg, and 93% at 20 mg dose.[93]
Olanzapine had the highest affinity of any second-generation antipsychotic towards theP-glycoprotein in onein vitro study.[94] P-glycoprotein transports a myriad of drugs across a number of different biological membranes (found in numerous body systems) including theblood–brain barrier (a semipermeable membrane that filters the contents of blood prior to it reaching the brain); P-GP inhibition could mean that less brain exposure to olanzapine results from this interaction with the P-glycoprotein.[95] A relatively large quantity of commonly encountered foods and medications inhibit P-GP, and pharmaceuticals fairly commonly are either substrates of P-GP or inhibit its action; both substrates and inhibitors of P-GP effectively increase the permeability of the blood-brain barrier to P-GP substrates and subsequently increase the central activity of the substrate, while reducing the local effects on the GI tract. The mediation of olanzapine in the central nervous system by P-GP means that any other substance or drug that interacts with P-GP increases the risk for toxic accumulations of both olanzapine and the other drug.[96]
Olanzapine is a potent antagonist of the muscarinic M3 receptor,[97] which may underlie its diabetogenic side effects.[98][99]Additionally, it also exhibits a relatively low affinity for serotonin 5-HT1, GABAA, β-adrenergic receptors, andbenzodiazepine binding sites.[42][100]
Although antagonistic effects of olanzapine at 5-HT2C alone are not associated with weight gain, olanzapine antagonism at histaminergic H1, muscarinic M3 and dopamine D2 receptors have been associated with weight gain and appetite stimulation.[90][101][102][103]
The mode of action of olanzapine's antipsychotic activity is unknown. It may involve antagonism ofdopamine andserotonin receptors. Antagonism of dopamine receptors is associated withextrapyramidal effects such astardive dyskinesia (TD), and with therapeutic effects. Antagonism ofmuscarinic acetylcholine receptors is associated withanticholinergic side effects such as dry mouth and constipation; in addition, it may suppress or reduce the emergence of extrapyramidal effects for the duration of treatment, but it offers no protection against the development of TD. In common with other second-generation (atypical) antipsychotics, olanzapine poses a relatively low risk of extrapyramidal side effects including TD, due to its higher affinity for the 5HT2A receptor over the D2 receptor.[104]
Olanzapine is metabolized by thecytochrome P450 (CYP) system; principally by isozyme 1A2 (CYP1A2) and to a lesser extent by CYP2D6. By these mechanisms, more than 40% of the oral dose, on average, is removed by thehepatic first-pass effect.[42]Clearance of olanzapine appears to vary by sex; women have roughly 25% lower clearance than men.[68] Clearance of olanzapine also varies by race; in self-identified African Americans or Blacks, olanzapine's clearance was 26% higher.[68] A difference in the clearance is not apparent between individuals identifying as Caucasian, Chinese, or Japanese.[68] Routine, pharmacokinetic monitoring of olanzapine plasma levels is generally unwarranted, though unusual circumstances (e.g. the presence of drug-drug interactions) or a desire to determine if patients are taking their medicine may prompt its use.[68]
Long-term treatment—in combination with fluoxetine—of resistant depression (March 2009)[110]
Oral formulation: acute and maintenance treatment of schizophrenia in adults, acute treatment of manic or mixed episodes associated with bipolar I disorder (monotherapy and in combination withlithium orsodium valproate)
Intramuscular formulation: acute agitation associated with schizophrenia and bipolar I mania in adults
Oral formulation combined with fluoxetine: treatment of acute depressive episodes associated with bipolar I disorder in adults, or treatment of acute, resistant depression in adults[111]
Treatment of the manifestations of psychotic disorders (September 1996[112] – March 2000).[113]
Short-term treatment of acute manic episodes associated with bipolar I disorder (March 2000)[113]
Short-term treatment of schizophrenia instead of the management of the manifestations of psychotic disorders (March 2000)[113]
Maintaining treatment response in schizophrenic patients who had been stable for about eight weeks and were then followed for a period of up to eight months (November 2000)[113]
The drug becamegeneric in 2011. Sales of Zyprexa in 2008 were $2.2 billion in the US and $4.7 billion worldwide.[114]
Eli Lilly has faced many lawsuits from people who claimed they developed diabetes or other diseases after taking Zyprexa, as well as by various governmental entities, insurance companies, and others. Lilly produced a large number of documents as part of thediscovery phase of this litigation, which started in 2004; the documents were ruled to be confidential by a judge and placed underseal, and later themselves became the subject of litigation.[115]
In 2006, Lilly paid $700 million to settle around 8,000 of these lawsuits,[116] and in early 2007, Lilly settled around 18,000 suits for $500 million, which brought the total Lilly had paid to settle suits related to the drug to $1.2 billion.[117][118]
A December 2006New York Times article based on leaked company documents concluded that the company had engaged in a deliberate effort to downplay olanzapine's side effects.[117][119] The company denied these allegations and stated that the article had been based on cherry-picked documents.[117][118] The documents were provided to theTimes byJim Gottstein, a lawyer who represented mentally ill patients, who obtained them from a doctor, David Egilman, who was serving as an expert consultant on the case.[115] After the documents were leaked to online peer-to-peer, file-sharing networks byWill Hall and others in thepsychiatric survivors movement, who obtained copies,[120] in 2007 Lilly filed a protection order to stop the dissemination of some of the documents, which JudgeJack B. Weinstein of the Brooklyn Federal District Court granted. Judge Weinstein also criticized theNew York Times reporter, Gottstein, and Egilman in the ruling.[115]The Times of London also received the documents and reported that as early as 1998, Lilly considered the risk of drug-induced obesity to be a "top threat" to Zyprexa sales.[118] On 9 October 2000, senior Lilly research physician Robert Baker noted that an academic advisory board to which he belonged was "quite impressed by the magnitude of weight gain on olanzapine and implications for glucose."[118]
Lilly had threatened Egilman with criminal contempt charges regarding the documents he took and provided to reporters; in September 2007, he agreed to pay Lilly $100,000 in return for the company's agreement to drop the threat of charges.[121]
In September 2008, Judge Weinstein issued an order to make public Lilly's internal documents about the drug in a different suit brought by insurance companies, pension funds, and other payors.[115]
In March 2008, Lilly settled a suit with the state of Alaska,[122] and in October 2008, Lilly agreed to pay $62 million to 32 states and the District of Columbia to settle suits brought under stateconsumer protection laws.[121]
In 2009, Eli Lilly pleaded guilty to a US federal criminalmisdemeanor charge of illegally marketing Zyprexa foroff-label use and agreed to pay $1.4 billion. The settlement announcement stated "Eli Lilly admits that between September 1999 and March 31, 2001, the company promoted Zyprexa in elderly populations as a treatment for dementia, including Alzheimer's dementia. Eli Lilly has agreed to pay a $515 million criminal fine and to forfeit an additional $100 million in assets."[123][124]
The outcomes described here, and their legal ramifications, were fueled by motions and appeals that were not resolved until 2010.[125] In 2021, Gottstein summarized this tangle of legal activities, and their impact on the political landscape of psychiatry and antipsychiatry in the US, inThe Zyprexa Papers.[126]
Olanzapine is marketed in many countries, with tablets ranging from 2.5 to 20 mg. Zyprexa (and generic olanzapine) is available as an orally disintegrating "wafer", which rapidly dissolves in saliva. It is also available in 10-mg vials for intramuscular injection.[69]
Olanzapine may be useful in promoting weight gain in underweight adult outpatients withanorexia nervosa. However, no improvement in psychological symptoms was noted.[127] It has also been shown to be helpful in the management of cancer-related anorexia.[14]
Olanzapine has been shown to help address a range of anxiety and depressive symptoms in individuals with schizophrenia and schizoaffective disorders, and has since been used in the treatment of a range of mood and anxiety disorders.[128] Olanzapine is no less effective thanlithium orvalproate and more effective than placebo in treating bipolar disorder.[129] It has also been used forTourette syndrome andstuttering.[130]
Olanzapine has been studied for the treatment of hyperactivity, aggressive behavior, and repetitive behaviors inautism.[131]
Olanzapine is frequently prescribed off-label for the treatment of insomnia, including difficulty falling asleep and staying asleep, even though such use is not recommended.[132] The daytime sedation experienced with olanzapine is generally comparable toquetiapine andlurasidone, which is a frequent complaint in clinical trials. In some cases, the sedation due to olanzapine impaired the ability of people to wake up at a consistent time every day. Some evidence of efficacy for treating insomnia is seen; however, side effects such asdyslipidemia andneutropenia, which may be observed even at low doses, outweigh any potential benefits for insomnia that are not due to an underlying mental health condition, and which can be treated effectively with FDA approved Z-drugs that do not present with the severe cardiometabolic adverse effects of antipsychotics and who present with very little to no potential for addiction compared with benzodiazepines.[133][134][135][136]
Olanzapine has been recommended to be used inantiemetic regimens in people receiving chemotherapy that has a high risk for vomiting.[137]
In general, olanzapine appears to be about as effective asaprepitant for the prevention of CINV, though some concerns remain about its use in this population. For example, concomitant use ofmetoclopramide or haloperidol increases the risk for extrapyramidal symptoms. Otherwise, olanzapine appears to be fairly well tolerated for this indication, with somnolence being the most common side effect.[139] Olanzapine is more effective than metoclopramide for breakthrough CINV.[140] It is also more effective than placebo when added to a combination of palonosetron, dexamethasone and aprepitant.[141]
Olanzapine has been considered as part of anearly psychosis approach for schizophrenia. The Prevention through Risk Identification, Management, and Education study, funded by theNational Institute of Mental Health and Eli Lilly, tested the hypothesis that olanzapine might prevent the onset of psychosis in people at very high risk for schizophrenia. The study examined 60 patients withprodromal schizophrenia, who were at an estimated risk of 36–54% of developing schizophrenia within a year and treated half with olanzapine and half with placebo.[142] In this study, patients receiving olanzapine did not have a significantly lower risk of progressing to psychosis (16.1% vs 37.9%). Olanzapine was effective for treating the prodromal symptoms but was associated with significant weight gain.[143]
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