Olanzapine

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Olanzapine
Olanzapine.svg
Olanzapine-from-xtal-3D-balls.png
Clinical data
Trade names Zyprexa (originator), many generics[1]
AHFS/Drugs.com Monograph
MedlinePlus a601213
License data
Pregnancy
category
  • AU: C
  • US: C (Risk not ruled out)
Routes of
administration		 oral, intramuscular
ATC code N05AH03 (WHO)
Legal status
Legal status
  • AU: S4 (Prescription only)
  • CA: ℞-only
  • NZ: Prescription Medicine
  • UK: POM (Prescription only)
  • US: ℞-only
Pharmacokinetic data
Bioavailability 87%[2]
Protein binding 93%[3]
Metabolism Hepatic (direct glucuronidation and CYP1A2 mediated oxidation)
Biological half-life 33 hours, 51.8 hours (elderly)[3]
Excretion Urine (57%; 7% as unchanged drug), faeces (30%)[3][4]
Identifiers
Systematic (IUPAC) name: 2-Methyl-4-(4-methyl-1-piperazinyl)-10H-thieno[2,3-b][1,5]benzodiazepine
CAS Number 132539-06-1 YesY
PubChem (CID) 4585
IUPHAR/BPS 47
DrugBank DB00334 YesY
ChemSpider 10442212 YesY
UNII N7U69T4SZR YesY
KEGG D00454 YesY
ChEBI CHEBI:7735 N
ChEMBL CHEMBL715 YesY
Chemical and physical data
Formula C17H20N4S
Molar mass 312.439
3D model (Jmol) Interactive image
Melting point 195 °C (383 °F)
Solubility in water Practically insoluble in water mg/mL (20 °C)
 NYesY (what is this?)  (verify)

Olanzapine (originally branded Zyprexa) is an atypical antipsychotic. It is approved by the U.S. Food and Drug Administration (FDA) for the treatment of schizophrenia and bipolar disorder.[5]

Olanzapine is structurally similar to clozapine and quetiapine. It is a dopamine antagonist and is classified as a thienobenzodiazepine.

Olanzapine was first made in the United Kingdom in 1982 by Eli Lilly. The drug became generic in 2011. Sales of Zyprexa in 2008 were $2.2B in the US, and $4.7B worldwide.[6]

Medical uses[edit]

Schizophrenia[edit]

The first-line psychiatric treatment for schizophrenia is antipsychotic medication which includes olanzapine.[7] A Cochrane review found, however, that the usefulness for maintenance therapy is difficult to determine as more than half of people in trials quit before the six-week completion date.[8][needs update]

Comparison[edit]

National Institute for Health and Care Excellence, the British Association for Psychopharmacology, and the World Federation of Societies for Biological Psychiatry suggest that there is little difference in effectiveness between antipsychotics in prevention of relapse, and recommend that the specific choice of antipsychotic be chosen based on persons preference and side effect profile.[9][10][11] The U.S. Agency for Healthcare Research and Quality concludes that olanzapine is not different from haloperidol in the treatment of positive symptoms and general psychopathology, or in overall assessment, but that it is superior for the treatment of negative and depressive symptoms. When trials enrolling only treatment-resistant patients were excluded from the analysis, olanzapine was superior for overall assessment.[12]

A 2013 review of first episode schizophrenia concluded that olanzapine is superior to haloperidol in providing a lower discontinuation rate, and in short-term symptom reduction, response rate, negative symptoms, depression, cognitive function, discontinuation due to poor efficacy, and long-term relapse, but not in positive symptoms or on the Clinical Global Impressions score. In contrast, pooled second generation antipsychotics showed superiority to first generation antipsychotics only against the discontinuation, negative symptoms (with a much larger effect seen among industry- compared to government-sponsored studies), and cognition scores. Olanzapine caused less extrapyramidal side effects, less akathisia, but caused significantly more weight gain, serum cholesterol increase, and triglyceride increase than haloperidol.[13] A 2012 review concluded that among 10 atypical antipsychotics, only clozapine, olanzapine, and risperidone were better than first generation antipsychotics.[14] A 2011 review concluded that neither first- nor second generation antipsychotics produce clinically meaningful changes in Clinical Global Impression scores but found that olanzapine and amisulpride produce larger effects on the PANSS and BPRS batteries than 5 other second generation antipsychotics or pooled first generation antipsychotics.[15]

A 2014 meta analysis of 9 published trials having minimum duration 6 months and median duration 52 weeks concluded that olanzapine, quetiapine, and risperidone had better effects on cognitive function than amisulpride and haloperidol.[16]

Olanzapine is effective in treating the acute exacerbations of schizophrenia.[17][18]

Bipolar disorder[edit]

Olanzapine is recommended by the National Institute of Health and Care Excellence as a first line therapy for the treatment of acute mania in bipolar disorder.[19] Other recommended first lines are haloperidol, quetiapine and risperidone.[19] It is recommended in combination with fluoxetine as a first line therapy for acute bipolar depression; and as a second line treatment by itself for the maintenance treatment of bipolar disorder.[19]

The Network for Mood and Anxiety Treatments (CANMAT) recommends olanzapine as a first line maintenance treatment in bipolar disorder and the combination of olanzapine with fluoxetine as second line treatment for bipolar depression.[20]

A 2014 meta analysis concluded that olanzapine plus fluoxetine was the most effective among nine treatments for bipolar depression included in the analysis.[21]

Other[edit]

Evidence does not support the use of atypical antipsychotics including olanzapine in eating disorders.[22]

Olanzapine has not been rigorously evaluated in generalized anxiety disorder, panic disorder, delusional parasitosis or post-traumatic stress disorder. Olanzapine is no less effective than lithium or valproate, and more effective than placebo in treating bipolar disorder.[23] It has also been used for Tourette syndrome and stuttering.[24]

Elderly[edit]

Citing an increased risk of stroke, in 2004 the Committee on the Safety of Medicines (CSM) 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 a black box warning for increased risk of death in elderly patients. It is not approved for use in patients with dementia-related psychosis.[25] However, a BBC investigation in June 2008 found that this advice was being widely ignored by British doctors.[26]

Adverse effects[edit]

See also: List of adverse effects of olanzapine

The principal side effect of olanzapine is weight gain, which may be profound in some cases and/or associated with derangement in the blood lipid and blood sugar profiles (see section metabolic effects). A recent 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 APD compared with a SMD of 0.74[27] Extrapyramidal side effects, although potentially serious, are infrequent to rare from olanzapine[28] but may include tremors and muscle rigidity.

Several patient groups are at a heightened risk of side effects from olanzapine and antipsychotics in general. Olanzapine may produce non-trivial high blood sugar in people with diabetes mellitus. Likewise, the elderly are at a greater risk of falls and accidental injury. Young males appear to be at heightened risk of dystonic 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 situations (exposure to heat, strenuous exercise) occur.[3][29][30][31][4]

Paradoxical effects[edit]

While olanzapine is used therapeutically to treat serious mental illness, occasionally it can have the opposite effect and provoke serious paradoxical reactions in a small subgroup of people, with the drug causing unusual changes in personality, thoughts or behavior; hallucinations and excessive thoughts about suicide have also been linked to olanzapine use.[32]

Metabolic effects[edit]

Direct glucuronidation and cytochrome P450 mediated oxidation are the primary metabolic pathways for olanzapine. In vitro studies suggest that CYPs 1A2 and 2D6, and the flavin-containing monooxygenase system are involved in olanzapine oxidation. CYP2D6 mediated oxidation appears to be a minor metabolic pathway in vivo. The U.S. Food and Drug Administration requires all atypical antipsychotics to include a warning about the risk of developing hyperglycemia and diabetes, both of which are factors in the metabolic syndrome. These effects may be related to the drugs' ability to induce weight gain, although there are some reports of metabolic changes in the absence of weight gain,[33][34] 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 one of the most likely to induce weight gain based on various measures.[35][36][37][38][39] The effect is dose dependent in humans[40] and animal models of olanzapine-induced metabolic side effects. There are some case reports of olanzapine-induced diabetic ketoacidosis.[41] Olanzapine may decrease insulin sensitivity,[42][43] though one 3-week study seems to refute this.[44] It may also increase triglyceride levels.[36]

Despite weight gain, a large multi-center randomized National 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.[45] One small, open-label, non-randomized study suggests that taking olanzapine by orally dissolving tablets may induce less weight gain,[46] but this has not been substantiated in a blinded experimental setting.

Pregnancy and lactation[edit]

Olanzapine is associated with the highest placental exposure of any atypical antipsychotic.[47] 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.[47] Olanzapine is associated with weight gain which according to recent studies may put olanzapine-treated patients' offspring at a heightened risk for neural tube defects (e.g. spina bifida).[48][49] Breastfeeding in women taking olanzapine is advised against due to the fact that olanzapine is secreted in breast milk with one study finding that the exposure to the infant (in mg per kg of body weight, that is) is about 1.8% that to the mother.[3]

Animal toxicology[edit]

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.[50]

Discontinuation[edit]

The British National Formulary recommends a gradual withdrawal when discontinuing anti-psychotic treatment to avoid acute withdrawal syndrome or rapid relapse.[51] Due to compensatory changes at dopamine, serotonin, adrenergic and histamine receptor sites in the central nervous system, withdrawal symptoms can occur during abrupt or over-rapid reduction in dosage. However, despite increasing demand for safe and effective antipsychotic withdrawal protocols or dose-reduction schedules, no specific guidelines with proven safety and efficacy are currently available. Support groups such as the Icarus Project, and other online forums provide resources and social support for those attempting to discontinue antipsychotics and other psychiatric medications.[52] Withdrawal symptoms reported to occur after discontinuation of antipsychotics include nausea, vomiting, lightheadedness, diaphoresis, dyskinesia, orthostatic hypotension, tachycardia, nervousness, dizziness, headache, excessive non-stop crying, and anxiety.[53][54] Some have argued additional somatic and psychiatric symptoms associated with dopaminergic hypersensitivity, including dyskinesia and acute psychosis, are common features of withdrawal in individuals treated with neuroleptics.[55][56][57][58] Thus, some suggest the withdrawal process itself may be schizo-mimetic, producing schizophrenia-like symptoms even in previously healthy patients.[59]

Overdose[edit]

Symptoms of an overdose include tachycardia, 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.[60] There is no known specific antidote for olanzapine overdose, and even physicians are recommended to call a certified poison control center for information on the treatment of such a case.[60] Olanzapine is considered moderately toxic in overdose; more toxic than quetiapine, aripiprazole and the SSRIs and less toxic than the MAOIs and TCAs.[47]

Pharmacology[edit]

Zyprexa (olanzapine) 10 mg tablets (AU)

Olanzapine has a higher affinity for 5-HT2A serotonin receptors than D2 dopamine receptors, which is a common property of all atypical antipsychotics, aside from the benzamide antipsychotics such as amisulpride. Olanzapine also had the highest affinity of any second-generation antipsychotic towards the P-glycoprotein in one in vitro study.[61] P-glycoprotein transports a number of drugs across a number of different biological membranes including the blood-brain barrier, which could mean that less brain exposure to olanzapine results from this interaction with the P-glycoprotein.[62]

Receptor Ki (nM)[63] Biologic action and notes[64]
5-HT1A 2282 Antagonist.
5-HT1B 585  ?
5-HT1D 1061  ?
5-HT1E 2209  ?
5-HT2A 2.4 Inverse agonist. May underlie the "atypicality" of the newer antipsychotics like olanzapine. May contribute to sedating effects.
5-HT2B 11.9 Inverse agonist/antagonist.
5-HT2C 10.2 Inverse agonist. May underlie the appetite-stimulating effects of olanzapine.
5-HT3 202 Antagonist. Possibly responsible, at least in part, for its antiemetic action.
5-HT5A 1212  ?
5-HT6 8.07 Antagonist.
5-HT7 105.2 Antagonist.
α1A 112 Antagonist. Likely responsible for the orthostatic hypotension seen with its use.[64]
α1B 263 Antagonist.
α2A 315 Antagonist.
α2B 81.8 Antagonist
α2C 28.9 Antagonist.
M1 26 Antagonist. Likely the chief receptor responsible for the anticholinergic effects seen with olanzapine's use.[64]
M2 63.5 Antagonist.
M3 52.67 Antagonist. Possible role in type 2 diabetes side-effects.[65]
M4 17.33 Antagonist.
M5 7.5 Antagonist.
D1 70.33 Antagonist.
D2 3.00 Antagonist. Likely responsible for the therapeutic effects of olanzapine against the positive symptoms of schizophrenia.[64]
D2Long 31 Antagonist.
D2Short 28.77 Antagonist.
D3 47 Antagonist.
D4 14.33 Antagonist.
D5 82 Antagonist.
H1 2.19 Inverse agonist. Likely responsible for the sedative effects of olanzapine.[64]
H2 44 Antagonist.
H4 >10000 Antagonist.

Olanzapine is a potent antagonist of the muscarinic M3 receptor,[66] which may underlie its diabetogenic side effects.[65][67] Additionally, olanzapine also exhibits a relatively low affinity for serotonin 5-HT1, GABAA, beta-adrenergic receptors, and benzodiazepine binding sites.[28][68]

The mode of action of olanzapine's antipsychotic activity is unknown. It may involve antagonism of dopamine and serotonin receptors. Antagonism of dopamine receptors is associated with extrapyramidal effects such as tardive dyskinesia(TD), and with therapeutic effects. Antagonism of muscarinic acetylcholine receptors is associated with anticholinergic 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, however it offers no protection against the development of tardive dyskinesia. In common with other second generation (atypical) antipsychotics, olanzapine poses a relatively low risk of extrapyramidal side effects including TD, due to its high affinity for the D1 receptor over the D2 receptor.[69]

Antagonizing H1 histamine receptors causes sedation and may cause weight gain, although antagonistic actions at serotonin 5-HT2C and dopamine D2 receptors have also been associated with weight gain and appetite stimulation.[70]

Metabolism[edit]

Olanzapine is metabolized by the cytochrome P450 system; principally by isozyme 1A2 and to a lesser extent by 2D6. By these mechanisms more than 40% of the oral dose, on average, is removed by the hepatic first-pass effect.[28] Drugs or agents that increase the activity of CYP1A2, notably tobacco smoke, may significantly increase hepatic first-pass clearance of Olanzapine; conversely, drugs which inhibit 1A2 activity (examples: Ciprofloxacin, Fluvoxamine) may reduce Olanzapine clearance.[5]

Society and culture[edit]

Regulatory status[edit]

Olanzapine is approved in the U.S.A. by the Food and Drug Administration (FDA) for:

  • Long-term treatment — in combination with fluoxetine — of resistant depression (March 2009).[74]
  • 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 with lithium or sodium 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[75]
  • Treatment of the manifestations of psychotic disorders (September 1996[76]—March 2000).[77]
  • Short-term treatment of acute manic episodes associated with bipolar I disorder (March 2000).[77]
  • Short-term treatment of schizophrenia instead of the management of the manifestations of psychotic disorders (March 2000).[77]
  • Maintaining treatment response in schizophrenic patients who had been stable for approximately eight weeks and were then followed for a period of up to eight months (November 2000).[77]

Controversy, prosecution, lawsuits and settlements[edit]

Eli Lilly has faced many lawsuits from people who claimed they developed diabetes or other diseases after taking Zyprexa. In 2006, Lilly paid $700 million to settle 8,000 of these lawsuits.[78] In 2007, Eli Lilly agreed to pay up to $500 million to settle 18,000 more lawsuits.[79]

In 2009, Eli Lilly pleaded guilty to a criminal misdemeanor charge of illegally marketing Zyprexa for off-label use and agreed to pay $1.4 billion.[80][81]

A New York Times article based on leaked company documents concluded that the company had engaged in a deliberate effort to downplay olanzapine's side effects.[82] The company denied these allegations and stated that the article had been based on cherry picked documents. Most of the documents were disclosed as the result of lawsuits by individuals who had taken the drug, though other documents had been stolen.[83] Eli Lilly filed a protection order to stop the dissemination of some of the documents which the judge believed to be confidential and "not generally appropriate for public consumption".[83] Temporary injunctions required those who had received the documents to return them and to remove them from websites.[84] Judge Jack B. Weinstein issued a permanent judgement against further dissemination of the documents and requiring their return by a number of parties named by Lilly.[83] On January 8, 2007, Judge Jack B. Weinstein refused the Electronic Frontier Foundation's motion to stay his order.[85] The documents given to The New York Times by Jim Gottstein show that senior Lilly executives may have kept important information from doctors about Zyprexa’s links to obesity and its tendency to raise blood sugar — both known risk factors for diabetes. The Times of London also reported that as early as 1998, Lilly considered the risk of drug-induced obesity to be a "top threat" to Zyprexa sales.[86] On October 9, 2000, senior Lilly research physician Robert Baker noted that an academic advisory board he belonged to was "quite impressed by the magnitude of weight gain on olanzapine and implications for glucose."[86]

Trade names[edit]

Olanzapine is generic and is available under many trade names worldwide.[1]

Dosage forms[edit]

Olanzapine is marketed in a number of countries, with tablets ranging from 2.5 to 20 milligrams. Zyprexa (and generic olanzapine) is available as an orally-disintegrating "wafer" which rapidly dissolves in saliva. It is also available in 10 milligram vials for intramuscular injection.[5]

Research[edit]

Olanzapine has been investigated for use as an antiemetic, particularly for the control of chemotherapy-induced nausea and vomiting (CINV). A 2007 study demonstrated its successful potential for this use, achieving a complete response in the acute prevention of nausea and vomiting in 100% of patients treated with moderately and highly-emetogenic chemotherapy, when used in combination with palonosetron and dexamethasone.[87]

Olanzapine has been considered as part of an early psychosis approach for schizophrenia. The Prevention through Risk Identification, Management, and Education (PRIME) study, funded by the National 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 with prodromal 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.[88] In this study, patients receiving olanzapine did not have a significantly lower risk of progressing to psychosis. Olanzapine was effective for treating the prodromal symptoms, but was associated with significant weight gain.[89]

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