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olanzapine
generic
Black Box Warnings .
Dementia-Related Psychosis
not approved for dementia-related psychosis; incr. mortality risk in elderly pts on antipsychotic tx for dementia-related psychosis; most deaths due to cardiovascular or infectious events
Adult Dosing .
Dosage forms: TAB: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg; ODT: 5 mg, 10 mg, 15 mg, 20 mg; INJ: 5 mg per mL
schizophrenia
- [10 mg PO qd]
- Start: 5-10 mg PO qd, may incr. 5 mg/day qwk; Max: 20 mg/day; Info: start 2.5-5 mg PO qd in non-smoker, elderly, debilitated or female pts or if hypotension risk; doses >10 mg/day rarely more effective; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
agitation, schizophrenia or bipolar I disorder-assoc.
- [10 mg IM x1]
- Max: 30 mg/day; Info: may repeat dose 2h after initial dose x1, then 4h after 2nd dose x1 prn; may give lower doses of 2.5-7.5 mg; consider 5 mg/dose in elderly and 2.5 mg/dose in non-smoker, debilitated or female pts or if hypotension risk; switch to PO ASAP; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
bipolar I disorder, manic/mixed
- [monotherapy]
- Dose: 5-20 mg PO qd; Start: 10-15 mg PO qd, may adjust by 5 mg/day prn; Max: 20 mg/day; Info: for acute and maintenance tx; start 5 mg PO qd in non-smoker, elderly, debilitated or female pts or if hypotension risk; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
- [valproate or lithium adjunct]
- Dose: 5-20 mg PO qd; Start: 10 mg PO qd, may adjust by 5 mg/day prn; Max: 20 mg/day; Info: for acute tx; start 5 mg PO qd in non-smoker, elderly, debilitated or female pts or if hypotension risk; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
bipolar I disorder, acute depressive
- [combo w/ fluoxetine]
- Dose: 5-12.5 mg PO qpm; Start: 5 mg PO qpm; Max: 12.5 mg/day; Info: may start 2.5 mg PO qpm in non-smoker, elderly or female pts or if hypotension risk; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
major depressive disorder, tx-resistant
- [combo w/ fluoxetine]
- Dose: 5-20 mg PO qpm; Start: 5 mg PO qpm; Max: 20 mg/day; Info: may start 2.5 mg PO qpm in non-smoker, elderly or female pts or if hypotension risk; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
nausea/vomiting prevention, chemo-related (off-label)
- [highly-emetogenic parenteral chemo]
- Dose: 5-10 mg PO x1 on day 1, then 5-10 mg PO qd on days 2-4; Info: part of multi-drug regimen; consider lower doses in elderly/debilitated pts or if poorly tolerated
- [moderately-emetogenic parenteral chemo]
- Dose: 5-10 mg PO x1 on day 1, then 5-10 mg PO qd on days 2-3; Info: part of multi-drug regimen; consider lower doses in elderly/debilitated pts or if poorly tolerated
refractory nausea/vomiting, chemo-related (off-label)
- [5-10 mg PO qd]
- Info: for breakthrough emesis if not used on days 1-4 as part of prophylactic regimen; consider lower doses in elderly/debilitated pts or if poorly tolerated
renal dosing
- [no adjustment]
- renal impairment: no adjustment
- HD/PD: no adjustment; no supplement
hepatic dosing
- [bipolar I disorder, acute depressive]
- hepatic impairment: start 2.5-5 mg qpm, titrate w/ caution
- [major depressive disorder, tx-resistant]
- hepatic impairment: start 2.5-5 mg qpm, titrate w/ caution
- [all other indications]
- hepatic impairment: not defined, caution advised
Peds Dosing .
- Dosage forms: TAB: 2.5 mg, 5 mg, 7.5 mg, 10 mg, 15 mg, 20 mg; ODT: 5 mg, 10 mg, 15 mg, 20 mg
schizophrenia
- [13-17 yo]
- Dose: 10 mg PO qd; Start: 2.5-5 mg PO qd; Max: 20 mg/day; Info: not first-line tx due to incr. in weight gain, hyperlipidemia; may adjust dose in 2.5-5 mg increments; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
bipolar I disorder, acute manic/mixed
- [13-17 yo]
- Dose: 10 mg PO qd; Start: 2.5-5 mg PO qd; Max: 20 mg/day; Info: not first-line tx due to incr. in weight gain, hyperlipidemia; may adjust dose in 2.5-5 mg increments; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
bipolar I disorder, acute depressive
- [combo w/ fluoxetine, 10-17 yo]
- Dose: 5-12.5 mg PO qpm; Start: 2.5 mg PO qpm; Max: 12.5 mg/day; Info: periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
renal dosing
- [no adjustment]
- renal impairment: no adjustment
- HD/PD: no adjustment; no supplement
hepatic dosing
- [see below]
- hepatic impairment: not defined, caution advised
Contraindications / Cautions .
- hypersensitivity to drug or ingredient
- caution: CNS depressant use, concurrent
- caution: alcohol use, concurrent
- caution: smoking habit change
- caution: elderly pts
- caution: leukopenia
- caution: neutropenia
- caution: leukopenia hx, drug-induced
- caution: neutropenia hx, drug-induced
- caution: hepatic impairment
- caution: hepatotoxic agent use, concurrent
- caution: cardiovascular dz
- caution: hypotension
- caution: hypovolemia
- caution: dehydration
- caution: diabetes mellitus
- caution: diabetes mellitus risk
- caution: urinary retention
- caution: urinary retention hx
- caution: prostatic hypertrophy
- caution: GI obstruction
- caution: GU obstruction
- caution: constipation
- caution: paralytic ileus hx
- caution: aspiration pneumonia risk
- caution: suicide risk
- caution: psychosis, dementia-associated
- caution: cerebrovascular dz
- caution: seizure hx
- caution: seizure risk
- caution: neuroleptic malignant syndrome hx
- caution: glaucoma, angle-closure
- caution: environmental temperature, high
- caution: PKU (phenylalanine-containing form)
Drug Interactions .
Overview
olanzapine
atypical antipsychotic
- CYP1A2 substrate
- CYP3A4 substrate
- anticholinergic effects
- CNS depression
- decreases central histamine effects
- dopamine antagonist
- extrapyramidal effects
- hyperglycemic effects
- hyperprolactinemic effects
- hyperthermia
- hypotensive effects
- lowers seizure threshold
Contraindicated
- potassium chloride
- potassium citrate
Avoid/Use Alternative
- aclidinium inhaled
- aldesleukin
- alosetron
- amantadine
- amifampridine
- apomorphine
- atropine ophthalmic
- botulinum toxin
- bromocriptine
- buprenorphine
- cabergoline
- clozapine
- codeine
- cyclopentolate ophthalmic
- darifenacin
- dexchlorpheniramine
- diazepam
- difenoxin
- dihydrocodeine
- doxepin topical
- doxylamine
- eluxadoline
- epinephrine
- erenumab
- ethanol
- fesoterodine
- flavoxate
- glucagon
- glycopyrrolate
- hydrocodone
- hyoscyamine
- isocarboxazid
- kava
- kratom
- levodopa
- levorphanol
- lofexidine
- lorazepam
- metaxalone
- metoclopramide
- midazolam
- molindone
- oxybate
- phenelzine
- pitolisant
- pramipexole
- pramlintide
- promethazine
- quinidine (antiarrhythmic)
- quinidine (CYP2D6 inhibitor)
- revefenacin inhaled
- ropeginterferon alfa-2b
- ropinirole
- rotigotine transdermal
- scopolamine
- solifenacin
- thalidomide
- thiothixene
- tolterodine
- tranylcypromine
- trihexyphenidyl
- trimethobenzamide
- tropicamide ophthalmic
- trospium
- zuranolone
Monitor/Modify Tx
- 5-HTP
- acarbose
- acebutolol
- alfentanil
- alfuzosin
- aliskiren
- allopurinol
- almotriptan
- alogliptin
- alprazolam
- amifostine
- amiloride
- amitriptyline
- amlodipine
- amoxapine
- apraclonidine ophthalmic
- aripiprazole
- aripiprazole bimonthly injection
- aripiprazole lauroxil
- articaine
- asenapine
- atenolol
- avanafil
- azilsartan medoxomil
- baclofen
- baclofen intrathecal
- benazepril
- berberine
- betaxolol
- betaxolol ophthalmic
- bethanechol
- bexagliflozin
- bisoprolol
- bortezomib
- brexanolone
- brexpiprazole
- brimonidine ophthalmic
- brimonidine topical
- brivaracetam
- brompheniramine
- bumetanide
- bupivacaine
- bupivacaine liposomal
- bupropion
- buspirone
- butalbital
- butorphanol
- canagliflozin
- candesartan cilexetil
- cannabidiol
- cannabis
- captopril
- carbamazepine
- carbinoxamine
- cariprazine
- carisoprodol
- carteolol ophthalmic
- carvedilol
- cenobamate
- cetirizine
- chamomile, German
- chlordiazepoxide
- chloroprocaine
- chlorothiazide
- chlorpheniramine
- chlorpromazine
- chlorthalidone
- chlorzoxazone
- cilostazol
- ciprofloxacin
- citalopram
- clemastine
- clevidipine
- clobazam
- clofarabine
- clomipramine
- clonazepam
- clonidine
- clorazepate
- coenzyme Q-10
- colesevelam
- cyclobenzaprine
- cyproheptadine
- dantrolene
- dapagliflozin
- daridorexant
- desflurane
- desipramine
- desvenlafaxine
- deutetrabenazine
- dexmedetomidine
- dexmedetomidine injection
- dichlorphenamide
- difelikefalin
- diltiazem
- dimenhydrinate
- dinutuximab
- diphenhydramine
- diphenoxylate
- dipyridamole
- domperidone
- doxazosin
- doxepin
- dronabinol
- droperidol
- dulaglutide
- duloxetine
- efavirenz
- eletriptan
- empagliflozin
- enalapril
- enalaprilat
- enasidenib
- entacapone
- entrectinib
- eplerenone
- epoprostenol
- ertugliflozin
- escitalopram
- esketamine
- eslicarbazepine acetate
- esmolol
- estazolam
- eszopiclone
- ethacrynic acid
- ethanol (in some formulations)
- ethosuximide
- etomidate
- exenatide
- felbamate
- felodipine
- fenfluramine
- fenoldopam
- fentanyl
- ferumoxytol
- flaxseed
- flibanserin
- fluoxetine
- fluphenazine
- fluvoxamine
- fosinopril
- fosphenytoin
- frovatriptan
- furosemide
- gabapentin
- gabapentin enacarbil
- ganaxolone
- garlic
- gilteritinib
- glimepiride
- glipizide
- glofitamab
- glyburide
- guanfacine
- haloperidol
- hydralazine
- hydrochlorothiazide
- hydromorphone
- hydroxyzine
- ifosfamide
- iloperidone
- iloprost
- iloprost inhaled
- imipramine
- indapamide
- insulin
- iobenguane I 131
- iohexol
- iopamidol
- irbesartan
- iron sucrose
- isoflurane
- isosorbide dinitrate
- isosorbide mononitrate
- isradipine
- ketamine
- labetalol
- lacosamide
- lamotrigine
- lasmiditan
- leflunomide
- lemborexant
- levetiracetam
- levobunolol ophthalmic
- levocetirizine
- levomilnacipran
- lidocaine
- linagliptin
- liraglutide
- lisinopril
- losartan
- loxapine
- lubiprostone
- lumateperone
- lurasidone
- magnesium sulfate
- maraviroc
- meclizine
- melatonin
- meperidine
- mepivacaine
- meprobamate
- metformin
- methadone
- methocarbamol
- methohexital
- methsuximide
- methyldopa
- methylene blue injection
- metolazone
- metoprolol
- metyrapone
- metyrosine
- milnacipran
- milrinone
- minoxidil
- mirtazapine
- mitotane
- moexipril
- morphine
- mosunetuzumab
- mycophenolate mofetil
- nadolol
- nalbuphine
- naltrexone
- naratriptan
- nateglinide
- nattokinase
- nebivolol
- nefazodone
- nelarabine
- niacin (vitamin B3)
- nicardipine
- nifedipine
- nimodipine
- nisoldipine
- nitric oxide
- nitrite
- nitroglycerin
- nitroprusside
- nortriptyline
- oliceridine
- olmesartan medoxomil
- opicapone
- opium
- orphenadrine
- oxazepam
- oxcarbazepine
- oxybutynin
- oxycodone
- oxymorphone
- paliperidone
- paroxetine
- passion flower
- pentamidine
- pentazocine
- pentobarbital
- perampanel
- perindopril
- perphenazine
- pheniramine
- phenobarbital
- phenoxybenzamine
- phentolamine
- phenytoin
- pimozide
- pindolol
- pioglitazone
- prazosin
- pregabalin
- primidone
- procarbazine
- prochlorperazine
- propofol
- propranolol
- protriptyline
- pyrilamine
- quazepam
- quetiapine
- quinapril
- ramelteon
- ramipril
- rasagiline
- remifentanil
- remimazolam
- repaglinide
- repotrectinib
- rifampin
- riociguat
- risperidone
- ritonavir
- rizatriptan
- ropivacaine
- rosiglitazone
- rufinamide
- sacubitril
- safinamide
- saxagliptin
- selegiline
- selegiline transdermal
- selinexor
- semaglutide
- sertraline
- sevoflurane
- sildenafil
- silodosin
- sitagliptin
- sodium ferric gluconate complex
- sotagliflozin
- sotalol
- sparsentan
- spironolactone
- St. John's wort
- stiripentol
- sufentanil
- sumatriptan
- suvorexant
- tadalafil
- tagraxofusp
- tamsulosin
- tapentadol
- tasimelteon
- taurine
- telmisartan
- temazepam
- terazosin
- teriflunomide
- tetrabenazine
- thioridazine
- tiagabine
- timolol
- timolol ophthalmic
- tirzepatide
- tizanidine
- tolcapone
- topiramate
- torsemide
- tramadol
- trandolapril
- trazodone
- treprostinil
- triamterene
- triazolam
- trifluoperazine
- trimipramine
- triprolidine
- valbenazine
- valerian
- valproic acid
- valsartan
- vardenafil
- venlafaxine
- verapamil
- vigabatrin
- vilazodone
- viloxazine
- vosoritide
- yohimbe
- zaleplon
- ziconotide
- ziprasidone
- zolmitriptan
- zolpidem
- zonisamide
Caution Advised
- acetazolamide
- apalutamide
- atropine
- barium
- belladonna alkaloids
- benztropine
- busulfan
- cevimeline
- chasteberry
- chlorambucil
- chloroquine
- cisapride
- clidinium
- degarelix
- dicyclomine
- disopyramide
- donepezil
- encorafenib
- enzalutamide
- erythromycin
- glycopyrrolate inhaled
- glycopyrronium topical
- goserelin
- histrelin
- homatropine
- hydroxychloroquine
- ipratropium inhaled
- ivosidenib
- leuprolide
- lindane topical
- lithium
- loperamide
- lumacaftor/ivacaftor
- magnesium citrate
- methscopolamine
- mexiletine
- mirabegron
- neostigmine
- pilocarpine
- pilocarpine ophthalmic
- polyethylene glycol
- polyethylene glycol/electrolytes
- potassium acid phosphate
- potassium gluconate
- potassium phosphate
- rifabutin
- sodium phosphate (bowel prep)
- sodium picosulfate
- solriamfetol
- sulfate bowel prep
- tiotropium inhaled
- triptorelin
- umeclidinium inhaled
- vibegron
Adverse Reactions .
Serious Reactions
- neuroleptic malignant syndrome
- extrapyramidal sx, severe
- tardive dyskinesia
- dystonia
- hyperglycemia
- diabetes mellitus
- diabetic ketoacidosis
- hyperlipidemia
- stroke
- venous thromboembolism
- hypotension, severe
- syncope
- dysphagia, severe
- aspiration
- hyperthermia
- anaphylactoid rxn
- angioedema
- drug rxn w/ eosinophilia and systemic sx
- seizures
- priapism
- intestinal obstruction
- hepatotoxicity
- pancreatitis
- rhabdomyolysis
- thrombocytopenia
- neutropenia
- leukopenia
- agranulocytosis
Common Reactions
- weight gain
- somnolence
- hyperprolactinemia
- extrapyramidal sx
- appetite incr.
- xerostomia
- dyslipidemia
- hyperglycemia
- headache
- asthenia
- insomnia
- dizziness
- tremor
- dyspepsia
- constipation
- back pain
- arthralgia
- speech disturbance
- amblyopia
- abdominal pain
- sialorrhea
- abnormal gait
- fever
- extremity pain
- amnesia
- paresthesia
- hypotension, orthostatic
- ecchymosis
- edema
- tachycardia
- LFTs elevated
- impaired body temperature regulation
Safety/Monitoring .
Monitoring Parameters
fasting glucose and lipid panel at baseline, then periodically; AST/ALT if significant hepatic dz; CBC w/ diff frequently during initial tx if pre-existing or hx of leukopenia/neutropenia; weight; s/sx orthostatic hypotension (IM use)
Look/Sound-Alike Drug Names
OLANZapine confused with: cetirizine; clonazePAM; olsalazine; ondansetron; OXcarbazepine; QUEtiapine; sertraline
Pregnancy/Lactation .
Pregnancy
Clinical Summary
weigh risk/benefit during pregnancy, esp. in 3rd trimester; consider monitoring glucose during pregnancy; risk of teratogenicity not expected based on human data; risk of neonatal extrapyramidal and withdrawal sx based on human data w/ antipsychotics; risk of gestational diabetes based on limited human data and drug's mechanism of action
Pregnancy Registry
encourage pts to enroll in National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or www.womensmentalhealth.org/research/pregnancyregistry/atypicalantipsychotic
Lactation
Clinical Summary
weigh risk/benefit while breastfeeding; no known risk of infant harm based on limited human data; no human data available to assess effects on milk production
Pharmacology .
Metabolism: liver extensively; CYP450: 1A2 (primary), 2D6 substrate; UGT: 1A4 substrate
Excretion: urine 57% (7% unchanged), feces 30%; Half-life: 21-54h
Subclass: Antiemetics, 2nd Generation Antipsychotics ; Antipsychotics, 2nd generation ; Bipolar Disorder
Mechanism of Action
exact mechanism of action unknown; antagonizes dopamine, serotonin 5-HT2, and other receptors (thienobenzodiazepine)
Formulary .
No Formulary Selected
Manufacturer/Pricing .
Manufacturer: generic
DEA/FDA: Rx
Approximate Retail Price
from http://www.goodrx.com/olanzapine
oral tablet:
- 2.5 mg (30 ea): $12.00
- 5 mg (30 ea): $12.00
- 7.5 mg (30 ea): $13.00
- 10 mg (30 ea): $13.00
- 15 mg (30 ea): $18.00
- 20 mg (30 ea): $19.00
oral disintegrating tablet:
- 5 mg (30 ea): $27.00
- 10 mg (30 ea): $33.00
- 15 mg (30 ea): $44.00
- 20 mg (30 ea): $39.00
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