OLANZAPINE (Page 3 of 12)

2.7 Olanzapine and Fluoxetine in Combination: Dosing in Special Populations

The starting dose of oral olanzapine 2.5 to 5 mg with fluoxetine 20 mg should be used for patients with a predisposition to hypotensive reactions, patients with hepatic impairment, or patients who exhibit a combination of factors that may slow the metabolism of olanzapine or fluoxetine in combination (female gender, geriatric age, nonsmoking status), or those patients who may be pharmacodynamically sensitive to olanzapine. Dosing modification may be necessary in patients who exhibit a combination of factors that may slow metabolism. When indicated, dose escalation should be performed with caution in these patients. Olanzapine and fluoxetine in combination have not been systematically studied in patients over 65 years of age or in patients under 10 years of age [see Warnings and Precautions (5.14), Drug Interactions (7), and Clinical Pharmacology (12.3)].

3 DOSAGE FORMS AND STRENGTHS

Olanzapine 2.5 mg tablets, USP are yellow colored, round, biconvex, uncoated tablets, debossed with “2.5” on one side and “66” on other side. The 5 mg tablets are yellow colored, round, biconvex, uncoated tablets, debossed with “5” on one side and “67” on other side. The 7.5 mg tablets are yellow colored, capsule shaped, biconvex, uncoated tablets, debossed with “7.5” on one side and “168” on other side. The 10 mg tablets are yellow colored, round, biconvex, uncoated tablets, debossed with “10” on one side and “169” on other side. The 15 mg tablets are yellow colored, oval shaped, biconvex, uncoated tablets, debossed with “15” on one side and “1170” on other side. The 20 mg tablets are yellow colored, round, biconvex, uncoated tablets, debossed with “20” on one side and “1171” on other side.

Olanzapine orally disintegrating 5 mg tablets, USP are yellow colored, round, flat, bevel edged uncoated tablets debossed with “86” on one side and “5” on other side. The 10 mg tablets are yellow colored, round, flat, bevel edged uncoated tablets debossed with “88” on one side and “10” on other side. The 15 mg tablets are yellow colored, round, flat, bevel edged uncoated tablets debossed with “89” on one side and “15” on other side. The 20 mg tablets are yellow colored, round, flat, bevel edged uncoated tablets debossed with “90” on one side and “20” on other side.

4 CONTRAINDICATIONS

  • None with olanzapine monotherapy.
  • When using olanzapine and fluoxetine in combination, also refer to the Contraindications section of the package insert for olanzapine and fluoxetine hydrochloride capsules.
  • For specific information about the contraindications of lithium or valproate, refer to the Contraindications section of the package inserts for these other products.

5 WARNINGS AND PRECAUTIONS

When using olanzapine and fluoxetine in combination, also refer to the Warnings and Precautions section of the package insert for olanzapine and fluoxetine hydrochloride capsules.

5.1 Elderly Patients with Dementia-Related Psychosis

Increased Mortality— Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Olanzapine is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning, Use in Specific Populations (8.5), and Patient Counseling Information (17)].

In placebo-controlled clinical trials of elderly patients with dementia-related psychosis, the incidence of death in olanzapine-treated patients was significantly greater than placebo-treated patients (3.5% vs 1.5%, respectively).

Cerebrovascular Adverse Events (CVAE), Including Stroke — Cerebrovascular adverse events (e.g., stroke, transient ischemic attack), including fatalities, were reported in patients in trials of olanzapine in elderly patients with dementia-related psychosis. In placebo-controlled trials, there was a significantly higher incidence of cerebrovascular adverse events in patients treated with olanzapine compared to patients treated with placebo. Olanzapine is not approved for the treatment of patients with dementia-related psychosis [see Boxed Warning and Patient Counseling Information (17)].

5.2 Suicide

The possibility of a suicide attempt is inherent in schizophrenia and in bipolar I disorder, and close supervision of high-risk patients should accompany drug therapy. Prescriptions for olanzapine should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.

5.3 Neuroleptic Malignant Syndrome (NMS)

A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs, including olanzapine. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac dysrhythmia). Additional signs may include elevated creatinine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure.

The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to exclude cases where the clinical presentation includes both serious medical illness (e.g., pneumonia, systemic infection, etc.) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever, and primary central nervous system pathology.

The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; 2) intensive symptomatic treatment and medical monitoring; and 3) treatment of any concomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for NMS.

If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported [see Patient Counseling Information (17)].

5.4 Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) has been reported with olanzapine exposure. DRESS may present with a cutaneous reaction (such as rash or exfoliative dermatitis), eosinophilia, fever, and/or lymphadenopathy with systemic complications such as hepatitis, nephritis, pneumonitis, myocardiatis, and/or pericardiatis. DRESS is sometimes fatal. Discontinue olanzapine if DRESS is suspected [see Patient Counseling Information (17)].

5.5 Metabolic Changes

Atypical antipsychotic drugs have been associated with metabolic changes including hyperglycemia, dyslipidemia, and weight gain. Metabolic changes may be associated with increased cardiovascular/cerebrovascular risk. Olanzapine’s specific metabolic profile is presented below.

Hyperglycemia and Diabetes Mellitus

Healthcare providers should consider the risks and benefits when prescribing olanzapine to patients with an established diagnosis of diabetes mellitus, or having borderline increased blood glucose level (fasting 100 to 126 mg/dL, nonfasting 140 to 200 mg/dL). Patients taking olanzapine should be monitored regularly for worsening of glucose control. Patients starting treatment with olanzapine should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug [see Patient Counseling Information (17)].

Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics including olanzapine. Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics. While relative risk estimates are inconsistent, the association between atypical antipsychotics and increases in glucose levels appears to fall on a continuum and olanzapine appears to have a greater association than some other atypical antipsychotics.

Mean increases in blood glucose have been observed in patients treated (median exposure of 9.2 months) with olanzapine in phase 1 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). The mean increase of serum glucose (fasting and nonfasting samples) from baseline to the average of the 2 highest serum concentrations was 15.0 mg/dL.

In a study of healthy volunteers, subjects who received olanzapine (N=22) for 3 weeks had a mean increase compared to baseline in fasting blood glucose of 2.3 mg/dL. Placebo-treated subjects (N=19) had a mean increase in fasting blood glucose compared to baseline of 0.34 mg/dL.

Olanzapine Monotherapy in Adults — In an analysis of 5 placebo-controlled adult olanzapine monotherapy studies with a median treatment duration of approximately 3 weeks, olanzapine was associated with a greater mean change in fasting glucose levels compared to placebo (2.76 mg/dL versus 0.17 mg/dL). The difference in mean changes between olanzapine and placebo was greater in patients with evidence of glucose dysregulation at baseline (patients diagnosed with diabetes mellitus or related adverse reactions, patients treated with anti-diabetic agents, patients with a baseline random glucose level ≥200 mg/dL, and/or a baseline fasting glucose level ≥126 mg/dL). Olanzapine-treated patients had a greater mean HbA1c increase from baseline of 0.04% (median exposure 21 days), compared to a mean HbA1c decrease of 0.06% in placebo-treated subjects (median exposure 17 days).

In an analysis of 8 placebo-controlled studies (median treatment exposure 4 to 5 weeks), 6.1% of olanzapine-treated subjects (N=855) had treatment-emergent glycosuria compared to 2.8% of placebo-treated subjects (N=599). Table 2 shows short-term and long-term changes in fasting glucose levels from adult olanzapine monotherapy studies.

Table 2: Changes in Fasting Glucose Levels from Adult Olanzapine Monotherapy Studies

* Not Applicable.

Up to 12 weeks exposure At least 48 weeks exposure
LaboratoryAnalyte Category Change (at least once) from Baseline Treatment Arm N Patients N Patients
Normal to High Olanzapine 543 2.2% 345 12.8%
Fasting (<100 mg/dL to ≥126 mg/dL) Placebo 293 3.4% NA * NA *
Glucose Borderline to High (≥100 mg/dL and <126 mg/dL Olanzapine 178 17.4% 127 26.0%
to ≥126 mg/dL) Placebo 96 11.5% NA * NA *

The mean change in fasting glucose for patients exposed at least 48 weeks was 4.2 mg/dL (N=487). In analyses of patients who completed 9 to 12 months of olanzapine therapy, mean change in fasting and nonfasting glucose levels continued to increase over time.

Olanzapine Monotherapy in Adolescents — The safety and efficacy of olanzapine have not been established in patients under the age of 13 years. In an analysis of 3 placebo-controlled olanzapine monotherapy studies of adolescent patients, including those with schizophrenia (6 weeks) or bipolar I disorder (manic or mixed episodes) (3 weeks), olanzapine was associated with a greater mean change from baseline in fasting glucose levels compared to placebo (2.68 mg/dL versus -2.59 mg/dL). The mean change in fasting glucose for adolescents exposed at least 24 weeks was 3.1 mg/dL (N=121). Table 3 shows short-term and long-term changes in fasting blood glucose from adolescent olanzapine monotherapy studies.

Table 3: Changes in Fasting Glucose Levels from Adolescent Olanzapine Monotherapy Studies

* Not Applicable.

Up to 12 weeks exposure At least 24 weeks exposure
Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm N Patients N Patients
Normal to High Olanzapine 124 0% 108 0.9%
Fasting (<100 mg/dL to ≥126 mg/dL) Placebo 53 1.9% NA * NA *
Glucose Borderline to High (≥100 mg/dL and <126 Olanzapine 14 14.3% 13 23.1%
mg/dL to ≥126 mg/dL) Placebo 13 0% NA * NA *

Dyslipidemia

Undesirable alterations in lipids have been observed with olanzapine use. Clinical monitoring, including baseline and periodic follow-up lipid evaluations in patients using olanzapine, is recommended [see Patient Counseling Information (17)].

Clinically significant, and sometimes very high (>500 mg/dL), elevations in triglyceride levels have been observed with olanzapine use. Modest mean increases in total cholesterol have also been seen with olanzapine use.

Olanzapine Monotherapy in Adults — In an analysis of 5 placebo-controlled olanzapine monotherapy studies with treatment duration up to 12 weeks, olanzapine-treated patients had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.3 mg/dL, 3.0 mg/dL, and 20.8 mg/dL respectively compared to decreases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 6.1 mg/dL, 4.3 mg/dL, and 10.7 mg/dL for placebo-treated patients. For fasting HDL cholesterol, no clinically meaningful differences were observed between olanzapine-treated patients and placebo-treated patients. Mean increases in fasting lipid values (total cholesterol, LDL cholesterol, and triglycerides) were greater in patients without evidence of lipid dysregulation at baseline, where lipid dysregulation was defined as patients diagnosed with dyslipidemia or related adverse reactions, patients treated with lipid lowering agents, or patients with high baseline lipid levels.

In long-term studies (at least 48 weeks), patients had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.6 mg/dL, 2.5 mg/dL, and 18.7 mg/dL, respectively, and a mean decrease in fasting HDL cholesterol of 0.16 mg/dL. In an analysis of patients who completed 12 months of therapy, the mean nonfasting total cholesterol did not increase further after approximately 4 to 6 months.

The proportion of patients who had changes (at least once) in total cholesterol, LDL cholesterol or triglycerides from normal or borderline to high, or changes in HDL cholesterol from normal or borderline to low, was greater in long-term studies (at least 48 weeks) as compared with short-term studies. Table 4 shows categorical changes in fasting lipids values.

Table 4: Changes in Fasting Lipids Values from Adult Olanzapine Monotherapy Studies

* Not Applicable

Up to 12 week exposure At least 48 week exposure
Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm N Patients N Patients
Increase by ≥50 Olanzapine 745 39.6% 487 61.4%
mg/dL Placebo 402 26.1% NA * NA *
Normal to High (<150 Olanzapine 457 9.2% 293 32.4%
Fasting mg/dL to ≥200 mg/dL) Placebo 251 4.4% NA * NA *
Triglycerides Borderline to High Olanzapine 135 39.3% 75 70.7%
(≥150 mg/dL and <200 mg/dL to ≥200 mg/dL) Placebo 65 20.0% NA * NA *
Increase by Olanzapine 745 21.6% 489 32.9%
≥40 mg/dL Placebo 402 9.5% NA * NA *
Normal to High Olanzapine 392 2.8% 283 14.8%
Fasting (<200 mg/dL to ≥240 mg/dL) Placebo 207 2.4% NA * NA *
Total Borderline to High Olanzapine 222 23.0% 125 55.2%
Cholesterol (≥200 mg/dL and <240 mg/dL to ≥240 mg/dL) Placebo 112 12.5% NA * NA *
Increase by Olanzapine 536 23.7% 483 39.8%
≥30 mg/dL Placebo 304 14.1% NA * NA *
Normal to High Olanzapine 154 0% 123 7.3%
Fasting LDL Cholesterol (<100 mg/dL to ≥160 mg/dL) Placebo 82 1.2% NA * NA *
Borderline to High Olanzapine 302 10.6% 284 31.0%
(≥100 mg/dL and <160 mg/dL to ≥160 mg/dL) Placebo 173 8.1% NA * NA *

In phase 1 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), over a median exposure of 9.2 months, the mean increase in triglycerides in patients taking olanzapine was 40.5 mg/dL. In phase 1 of CATIE, the mean increase in total cholesterol was 9.4 mg/dL.

Olanzapine Monotherapy in Adolescents — The safety and efficacy of olanzapine have not been established in patients under the age of 13 years. In an analysis of 3 placebo-controlled olanzapine monotherapy studies of adolescents, including those with schizophrenia (6 weeks) or bipolar I disorder (manic or mixed episodes) (3 weeks), olanzapine-treated adolescents had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 12.9 mg/dL, 6.5 mg/dL, and 28.4 mg/dL, respectively, compared to increases from baseline in mean fasting total cholesterol and LDL cholesterol of 1.3 mg/dL and 1.0 mg/dL, and a decrease in triglycerides of 1.1 mg/dL for placebo-treated adolescents. For fasting HDL cholesterol, no clinically meaningful differences were observed between olanzapine-treated adolescents and placebo-treated adolescents.

In long-term studies (at least 24 weeks), adolescents had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.5 mg/dL, 5.4 mg/dL, and 20.5 mg/dL, respectively, and a mean decrease in fasting HDL cholesterol of 4.5 mg/dL. Table 5 shows categorical changes in fasting lipids values in adolescents.

Table 5: Changes in Fasting Lipids Values from Adolescent Olanzapine Monotherapy Studies

a Not Applicable.

Up to 6 weeks exposure At least 24 weeks exposure
Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm N Patients N Patients
Increase by ≥50 mg/dL Olanzapine 138 37.0% 122 45.9%
Placebo 66 15.2% NA a NA a
Normal to High Olanzapine 67 26.9% 66 36.4%
Fasting (<90 mg/dL to >130 mg/dL) Placebo 28 10.7% NA a NA a
Triglycerides Borderline to High (≥90 mg/dL and Olanzapine 37 59.5% 31 64.5%
≤130 mg/dL to >130 mg/dL) Placebo 17 35.3% NA a NA a
Increase by ≥40 mg/dL Olanzapine 138 14.5% 122 14.8%
Placebo 66 4.5% NA a NA a
Normal to High (<170mg/dL to Olanzapine 87 6.9% 78 7.7%
Fasting ≥200 mg/dL) Placebo 43 2.3% NA a NA a
Total Cholesterol Borderline to High Olanzapine 36 38.9% 33 57.6%
(≥170mg/dL and <200 mg/dL to ≥200 mg/dL) Placebo 13 7.7% NA a NA a
Increase by ≥30 mg/dL Olanzapine 137 17.5% 121 22.3%
Placebo 63 11.1% NA a NA a
Fasting Normal to High Olanzapine 98 5.1% 92 10.9%
LDL Cholesterol (<110 mg/dL to ≥130 mg/dL) Placebo 44 4.5% NA a NA a
Borderline to High Olanzapine 29 48.3% 21 47.6%
(≥110 mg/dL and <130 mg/dL to ≥130 mg/dL) Placebo 9 0% NA a NA a

Weight Gain

Potential consequences of weight gain should be considered prior to starting olanzapine. Patients receiving olanzapine should receive regular monitoring of weight [see Patient Counseling Information (17)].

Olanzapine Monotherapy in Adults — In an analysis of 13 placebo-controlled olanzapine monotherapy studies, olanzapine-treated patients gained an average of 2.6 kg (5.7 lb) compared to an average 0.3 kg (0.6 lb) weight loss in placebo-treated patients with a median exposure of 6 weeks; 22.2% of olanzapine-treated patients gained at least 7% of their baseline weight, compared to 3% of placebo-treated patients, with a median exposure to event of 8 weeks; 4.2% of olanzapine-treated patients gained at least 15% of their baseline weight, compared to 0.3% of placebo-treated patients, with a median exposure to event of 12 weeks. Clinically significant weight gain was observed across all baseline Body Mass Index (BMI) categories. Discontinuation due to weight gain occurred in 0.2% of olanzapine-treated patients and in 0% of placebo-treated patients.

In long-term studies (at least 48 weeks), the mean weight gain was 5.6 kg (12.3 lb) (median exposure of 573 days, N=2,021). The percentages of patients who gained at least 7%, 15%, or 25% of their baseline body weight with long-term exposure were 64%, 32%, and 12%, respectively. Discontinuation due to weight gain occurred in 0.4% of olanzapine-treated patients following at least 48 weeks of exposure.

Table 6 includes data on adult weight gain with olanzapine pooled from 86 clinical trials. The data in each column represent data for those patients who completed treatment periods of the durations specified.

Table 6: Weight Gain with Olanzapine Use in Adults
Amount Gained kg (lb) 6 Weeks (N=7,465) (%) 6 Months (N=4,162) (%) 12 Months (N=1,345) (%) 24 Months (N=474) (%) 36 Months (N=147) (%)
≤0 26.2 24.3 20.8 23.2 17.0
0 to ≤5 (0 to11 lb) 57.0 36.0 26.0 23.4 25.2
>5 to ≤10 (11 to 22 lb) 14.9 24.6 24.2 24.1 18.4
>10 to ≤15 (22 to 33 lb) 1.8 10.9 14.9 11.4 17.0
>15 to ≤20 (33 to 44 lb) 0.1 3.1 8.6 9.3 11.6
>20 to ≤25 (44 to 55 lb) 0 0.9 3.3 5.1 4.1
>25 to ≤30 (55 to 66 lb) 0 0.2 1.4 2.3 4.8
>30 (>66 lb) 0 0.1 0.8 1.2 2

Dose group differences with respect to weight gain have been observed. In a single 8-week randomized, double-blind, fixed-dose study comparing 10 (N=199), 20 (N=200) and 40 (N=200) mg/day of oral olanzapine in adult patients with schizophrenia or schizoaffective disorder, mean baseline to endpoint increase in weight (10 mg/day: 1.9 kg; 20 mg/day: 2.3 kg; 40 mg/day: 3 kg) was observed with significant differences between 10 vs 40 mg/day.

Olanzapine Monotherapy in Adolescents — The safety and efficacy of olanzapine have not been established in patients under the age of 13 years. Mean increase in weight in adolescents was greater than in adults. In 4 placebo-controlled trials, discontinuation due to weight gain occurred in 1% of olanzapine-treated patients, compared to 0% of placebo-treated patients.

Table 7: Weight Gain with Olanzapine Use in Adolescents from 4 Placebo-Controlled Trials
Olanzapine-treated patients Placebo-treated patients
Mean change in body weight from baseline (median exposure = 3 weeks) 4.6 kg (10.1 lb) 0.3 kg (0.7 lb)
Percentage of patients who gained at least 7% of baseline body weight 40.6% (median exposure to 7%= 4 weeks) 9.8% (median exposure to 7% = 8 weeks)
Percentage of patients who gained at least 15% of baseline body weight 7.1% (median exposure to 15% = 19 weeks) 2.7% (median exposure to 15% = 8 weeks)

In long-term studies (at least 24 weeks), the mean weight gain was 11.2 kg (24.6 lb); (median exposure of 201 days, N=179). The percentages of adolescents who gained at least 7%, 15%, or 25% of their baseline body weight with long-term exposure were 89%, 55%, and 29%, respectively. Among adolescent patients, mean weight gain by baseline BMI category was 11.5 kg (25.3 lb), 12.1 kg (26.6 lb), and 12.7 kg (27.9 lb), respectively, for normal (N=106), overweight (N=26) and obese (N=17). Discontinuation due to weight gain occurred in 2.2% of olanzapine-treated patients following at least 24 weeks of exposure.

Table 8 shows data on adolescent weight gain with olanzapine pooled from 6 clinical trials. The data in each column represent data for those patients who completed treatment periods of the durations specified. Little clinical trial data is available on weight gain in adolescents with olanzapine beyond 6 months of treatment.

Table 8: Weight Gain with Olanzapine Use in Adolescents
Amount Gained kg (lb) 6 Weeks (N=243) (%) 6 Months (N=191) (%)
≤0 2.9 2.1
0 to ≤5 (0 to 11 lb) 47.3 24.6
>5 to ≤10 (11 to 22 lb) 42.4 26.7
>10 to ≤15 (22 to 33 lb) 5.8 22.0
>15 to ≤20 (33 to 44 lb) 0.8 12.6
>20 to ≤25 (44 to 55 lb) 0.8 9.4
>25 to ≤30 (55 to 66 lb) 0 2.1
>30 to ≤35 (66 to 77 lb) 0 0
>35 to ≤40 (77 to 88 lb) 0 0
>40 (>88 lb) 0 0.5

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