From the Guidelines
To safely discontinue olanzapine in a 77-year-old woman with dementia and behavioral issues while increasing valproic acid, I recommend a gradual taper of olanzapine over 2-4 weeks while simultaneously titrating up the valproic acid. This approach is supported by the most recent and highest quality study available, which emphasizes the importance of gradual withdrawal of antipsychotics to minimize potential discontinuation effects 1. The patient is currently on olanzapine 5mg bid and valproic acid 125mg bid, and the goal is to discontinue olanzapine while increasing valproic acid to 250mg bid. Start by reducing the olanzapine dose by 25-50% every 5-7 days while monitoring for withdrawal symptoms or behavioral worsening. For example, reduce the olanzapine dose from 5mg bid to 2.5mg bid for one week, then to 1.25mg bid for another week before stopping completely. During this taper, begin increasing the valproic acid dose to the target dose of 250mg bid. Throughout this transition, closely monitor for side effects of valproic acid including sedation, tremor, and gastrointestinal disturbances. Regular blood tests to check valproic acid levels, liver function, and complete blood count are essential, aiming for a therapeutic valproic acid level of 50-100 μg/mL, as suggested by guidelines for managing Alzheimer's disease 1. This gradual approach minimizes the risk of withdrawal symptoms from olanzapine (such as rebound psychosis, insomnia, or anxiety) while allowing the valproic acid to reach therapeutic levels. In elderly patients with dementia, medication changes should be made slowly due to increased sensitivity to both therapeutic effects and adverse reactions. Some key points to consider during this transition include:
- Monitoring for signs of valproic acid toxicity, such as tremor, drowsiness, or confusion
- Adjusting the valproic acid dose based on blood levels and clinical response
- Providing education and support to the patient and caregivers on the importance of gradual medication changes and monitoring for potential side effects.
From the Research
Discontinuing Olanzapine Safely
To discontinue olanzapine safely in a 77-year-old woman with dementia and behavioral issues, while increasing valproic acid to 250mg bid, consider the following steps:
- Gradually taper off olanzapine over a period of months or longer, as suggested by studies 2, 3, to minimize the risk of relapse and withdrawal symptoms.
- Reduce the dose of olanzapine in small increments, especially at lower doses, to minimize the disruption of homeostatic equilibrium and the risk of psychotic symptoms 2.
- Consider a hyperbolic tapering schedule, where the dose is reduced by a smaller amount each time, to reduce the risk of relapse and withdrawal symptoms 4, 3.
- Monitor the patient closely for signs of withdrawal symptoms, such as insomnia, anxiety, or agitation, and adjust the tapering schedule as needed.
Interaction between Valproic Acid and Olanzapine
- Valproic acid may decrease the plasma concentrations of olanzapine, although the effect is likely to be minimal and not clinically significant 5.
- However, the patient is already taking valproic acid, and the dose is being increased to 250mg bid, so the potential interaction should be monitored closely.
Tapering Schedule
- A possible tapering schedule for olanzapine could be:
- Reduce the dose by 2.5mg every 2-4 weeks, depending on the patient's tolerance and response.
- Monitor the patient closely for signs of withdrawal symptoms or relapse, and adjust the tapering schedule as needed.
- Consider reducing the dose more slowly, such as by 1.25mg every 2-4 weeks, if the patient experiences any withdrawal symptoms or relapse.
Important Considerations
- The patient's age and medical condition should be taken into account when tapering off olanzapine, as older adults may be more susceptible to withdrawal symptoms and relapse 2, 6.
- The patient's behavioral issues and dementia should also be monitored closely, as the tapering off of olanzapine may affect these conditions 2.