Should I taper olanzapine or Seroquel first in a patient with resolved auditory hallucinations and ongoing muscle spasms and constipation?

Taper Quetiapine First in Patient with Resolved Auditory Hallucinations and Ongoing Side Effects

When tapering antipsychotics in a patient with resolved auditory hallucinations but ongoing muscle spasms and constipation, quetiapine should be tapered first while maintaining olanzapine, which has been more effective for controlling hallucinations. 1

Rationale for Tapering Decision

Effectiveness for Target Symptoms

• Olanzapine has successfully eliminated the patient's auditory hallucinations since its recent addition 2
• The combination of olanzapine 15mg and quetiapine 300mg is causing side effects (muscle spasms, constipation) and elevated CK (216)
• Maintaining symptom control of hallucinations is the primary concern for morbidity and mortality outcomes

Medication Properties and Side Effect Profiles

1. Olanzapine:

   • Effective for controlling hallucinations in schizophrenia spectrum disorders 2
   • Generally well tolerated at therapeutic doses 1
   • Can cause metabolic effects with long-term use 1

2. Quetiapine:

   • More sedating than olanzapine 1
   • Can cause orthostatic hypotension and dizziness 1
   • Available only in oral formulations 1

Tapering Algorithm

Step 1: Begin Quetiapine Taper

• Reduce quetiapine by 50mg every 1-2 weeks 1, 3
• Suggested schedule:
  • Week 1-2: 250mg daily
  • Week 3-4: 200mg daily
  • Week 5-6: 150mg daily
  • Continue until discontinued

Step 2: Monitor for Symptom Recurrence

• Assess for return of auditory hallucinations at each dose reduction
• If hallucinations return, return to previous effective dose of quetiapine

Step 3: Address Side Effects During Taper

• For muscle spasms:
  • Consider adding low-dose anticholinergic if extrapyramidal symptoms worsen during taper
  • Monitor CK levels to track improvement
• For constipation:
  • Recommend increased fluid intake, dietary fiber, and exercise
  • Consider mild laxatives if needed

Step 4: Maintain Olanzapine

• Continue olanzapine at current effective dose (15mg)
• Consider gradual dose reduction of olanzapine only after complete discontinuation of quetiapine and continued absence of hallucinations

Clinical Considerations

Why Taper Quetiapine First

1. Following the principle that when a patient is on two medications for the same disorder, the first medication to be removed should be the adjunctive agent 1
2. The recent addition of olanzapine has specifically resolved the hallucinations, suggesting it is the more effective agent for this patient 1
3. Quetiapine is more sedating and can cause orthostatic hypotension, which may contribute to the patient's side effects 1

Monitoring Parameters

• Weekly assessment for return of psychotic symptoms
• CK levels to monitor for improvement in muscle symptoms
• Constipation symptoms
• Sleep quality and daytime sedation

Potential Pitfalls to Avoid

• Tapering too quickly, which may lead to withdrawal symptoms or symptom recurrence
• Discontinuing both medications simultaneously, which significantly increases risk of psychotic relapse
• Failing to monitor for the emergence of withdrawal symptoms during the taper
• Ignoring physical side effects that may persist despite tapering

If the patient continues to experience muscle spasms and elevated CK despite quetiapine discontinuation, consider a gradual reduction of olanzapine dose while maintaining symptom control of hallucinations.