What is the recommended starting dose of Zyprexa (olanzapine)?

Recommended Starting Dose of Zyprexa (Olanzapine)

The recommended starting dose of Zyprexa (olanzapine) is 2.5 mg per day at bedtime for treatment of problematic delusions, hallucinations, severe psychomotor agitation, and combativeness. 1

Dosing Guidelines Based on Indication

For Schizophrenia:

• Adults:

  • Initial dose: 5-10 mg once daily 2
  • Target dose: 10 mg/day within several days
  • Maximum dose: 20 mg/day
  • Lower starting dose (5 mg) recommended for:
    • Debilitated patients
    • Those with predisposition to hypotensive reactions
    • Elderly non-smoking females (≥65 years)
    • Patients who may be more pharmacodynamically sensitive

• Adolescents:

  • Initial dose: 2.5-5 mg once daily 2
  • Target dose: 10 mg/day
  • Maximum dose: 20 mg/day

For Bipolar I Disorder (Manic or Mixed Episodes):

• Adults:

  • Initial dose: 10-15 mg once daily 2
  • Maximum dose: 20 mg/day

• Adolescents:

  • Initial dose: 2.5-5 mg once daily 2
  • Target dose: 10 mg/day
  • Maximum dose: 20 mg/day

For Delirium/Agitation in Palliative Care:

• Initial dose: 2.5-5 mg once daily 1
• Can be given orally or subcutaneously

Clinical Considerations for Starting Dose

Lower Starting Doses (2.5 mg) Are Recommended For:

• Elderly patients
• Frail patients
• Patients with hepatic impairment
• Patients with risk factors for orthostatic hypotension
• Patients with dementia-related psychosis or agitation

Common Side Effects to Monitor:

• Weight gain
• Drowsiness
• Orthostatic hypotension
• Metabolic effects (with long-term use)

Important Cautions

1. Titration Schedule: Dosage adjustments should generally occur at intervals of not less than 1 week for adults with schizophrenia, as steady state is not achieved for approximately 1 week 2.

2. Efficacy Ceiling: Doses above 10 mg/day have not been demonstrated to be more efficacious than 10 mg/day for schizophrenia, though individual patients may benefit from higher doses 2, 3.

3. Safety Concerns: Olanzapine is generally well tolerated compared to typical antipsychotics, with lower risk of extrapyramidal symptoms 1, 4.

4. Monitoring Requirements: Regular monitoring for metabolic effects, weight gain, and other side effects is essential.

5. Special Populations: Starting with 2.5 mg is particularly important in elderly patients, where lower doses can achieve therapeutic effect with reduced risk of adverse events 1.

Practical Dosing Algorithm

1. Assess patient characteristics:

   • Age (elderly vs. younger)
   • Body weight/frailty
   • Indication (schizophrenia, bipolar disorder, delirium)
   • Comorbidities (especially hepatic impairment)

2. Select appropriate starting dose:

   • Standard adult: 5-10 mg once daily
   • Elderly, frail, or at-risk patients: 2.5 mg once daily
   • Adolescents: 2.5-5 mg once daily

3. Administration timing:

   • Generally administered at bedtime to minimize daytime sedation
   • Can be given without regard to meals 2

4. Titration approach:

   • Wait at least 1 week before dose increases
   • Increase in increments of 2.5-5 mg based on response and tolerability
   • Target lowest effective dose that maintains symptom control

By starting at an appropriate dose based on patient characteristics and indication, you can maximize therapeutic benefit while minimizing adverse effects.