Can I give a one-time order of Zyprexa (olanzapine) to a patient with a history of seizures and mental disorders who remains agitated despite treatment with Ativan (lorazepam) PO and Haldol (haloperidol) PRN?

Management of Acute Agitation in a Patient with History of Seizures

Yes, a one-time order of Zyprexa (olanzapine) is appropriate for this patient who remains agitated despite treatment with Ativan (lorazepam) and Haldol (haloperidol). Olanzapine is an effective option for managing acute agitation in patients with psychiatric disorders and can be used as part of a stepwise approach when initial medications have failed to achieve adequate control.

Rationale for Using Olanzapine

Olanzapine is recommended as an effective monotherapy for both management of agitation and initial drug therapy for patients with known psychiatric illness 1. The clinical guidelines support using atypical antipsychotics like olanzapine for controlling problematic delusions, hallucinations, severe psychomotor agitation, and combativeness 1.

Key advantages of olanzapine in this situation:

• Generally well tolerated compared to typical antipsychotics 1
• Lower risk of extrapyramidal symptoms than haloperidol 2
• Effective in rapidly reducing symptoms of acute agitation 3
• Can be used after benzodiazepines and typical antipsychotics have failed to control agitation 1

Dosing Considerations

For this patient who has already received Ativan and Haldol:

• Initial oral olanzapine dose: 2.5-5 mg 1
• Can be titrated up to 10 mg if needed, usually given twice daily in divided doses 1
• For severe agitation, doses up to 20 mg have been studied and shown to be effective 4

Special Considerations for Seizure History

The patient's history of seizures requires careful consideration:

• Olanzapine has a lower seizure risk compared to some other antipsychotics
• Monitor closely for any signs of seizure activity
• Avoid rapid dose escalation which might lower seizure threshold
• Consider that the benzodiazepine (Ativan) already administered provides some seizure protection

Monitoring After Administration

After administering olanzapine:

1. Monitor vital signs, particularly blood pressure and heart rate, as transient reductions may occur 3
2. Assess level of sedation and agitation every 15-30 minutes
3. Watch for potential side effects including:
   • Excessive sedation
   • Orthostatic hypotension
   • Extrapyramidal symptoms (though these are less common with olanzapine)
   • QT prolongation (though olanzapine has less QTc effect than some other antipsychotics) 1

Alternative Approaches if Olanzapine Fails

If olanzapine is ineffective or contraindicated:

• Consider ziprasidone as an alternative atypical antipsychotic 1, 5
• For severe, persistent agitation, combination therapy with a benzodiazepine and an antipsychotic may be more effective than monotherapy 1
• In cases of extreme agitation, parenteral administration may be necessary 5

Pitfalls to Avoid

1. Avoid using multiple antipsychotics simultaneously, which increases side effect risk without clear benefit
2. Be cautious about respiratory depression when combining olanzapine with the previously administered lorazepam
3. Don't overlook medical causes of agitation that may require specific treatment
4. Remember that olanzapine carries FDA warnings about increased mortality in elderly patients with dementia-related psychosis 6

Olanzapine represents an appropriate next step in managing this patient's continued agitation after lorazepam and haloperidol have proven insufficient, particularly given the patient's history of seizures and psychiatric disorders.