What is the appropriate dosing and administration of olanzapine (olanzapine) intramuscularly (IM) for a psychotic break in the Emergency Room (ER)?

Olanzapine IM for Psychotic Break in the Emergency Room

The recommended dose of intramuscular olanzapine for acute agitation in a psychotic break is 10 mg, with lower doses of 5 mg or 7.5 mg considered when clinical factors warrant. 1

Dosing Guidelines

• The FDA-approved dose range for intramuscular olanzapine in controlling agitation associated with schizophrenia and bipolar I mania is 2.5 mg to 10 mg, with 10 mg being the standard recommended dose 1
• Lower doses should be considered in specific populations:
  • 5 mg for geriatric patients or when other clinical factors warrant 1
  • 2.5 mg for patients who might be debilitated, predisposed to hypotensive reactions, or more pharmacodynamically sensitive to olanzapine 1

Administration Technique

• Olanzapine for injection is intended for intramuscular use only - do not administer intravenously or subcutaneously 1
• Inject slowly, deep into the muscle mass 1
• Reconstitution instructions:
  • Dissolve contents of the vial using 2.1 mL of Sterile Water for Injection to provide a solution containing approximately 5 mg/mL 1
  • The resulting solution should appear clear and yellow 1
  • Use immediately (within 1 hour) after reconstitution 1
  • Discard any unused portion 1

Repeat Dosing Considerations

• If agitation persists following the initial dose, subsequent doses up to 10 mg may be given 1
• Important safety limitations:
  • The efficacy of repeated doses has not been systematically evaluated in controlled trials 1
  • Safety concerns exist for total daily doses greater than 30 mg 1
  • 10 mg injections should not be given more frequently than 2 hours after the initial dose, and 4 hours after the second dose 1
  • Maximal dosing (e.g., 3 doses of 10 mg administered 2-4 hours apart) may cause significant orthostatic hypotension 1
  • Patients requiring subsequent injections should be assessed for orthostatic hypotension prior to administration of additional doses 1

Efficacy Evidence

• Clinical trials have demonstrated that olanzapine IM is effective in rapidly reducing agitation in patients with schizophrenia and bipolar I disorder 1
• Efficacy was established in three short-term (24 hours) placebo-controlled trials in agitated adult inpatients 1
• The primary efficacy measure was change from baseline in the PANSS Excited Component at 2 hours post-injection, with olanzapine showing statistical superiority to placebo 1

Special Considerations and Precautions

• Olanzapine IM should not be combined in a syringe with:

  • Diazepam injection (precipitation occurs) 1
  • Lorazepam injection (delayed reconstitution time) 1
  • Haloperidol injection (low pH degrades olanzapine over time) 1

• Use caution when using olanzapine IM and parenteral benzodiazepines simultaneously, as fatalities have been reported with concurrent use 2, 3

• Common side effects include:

  • Somnolence, agitation, insomnia, and headache 4
  • Sedation and potential respiratory suppression, especially when used with other sedative agents 5
  • Fatigue, drowsiness, and sleep disturbances 5

• Olanzapine should be used with caution in elderly patients due to increased risk of death in patients with dementia-related psychosis 5, 1

Transition to Oral Therapy

• If ongoing olanzapine therapy is clinically indicated, oral olanzapine may be initiated in a range of 5 to 20 mg/day as soon as clinically appropriate 1

Clinical Effectiveness

• Studies have shown that olanzapine IM is effective in rapidly calming agitation in acutely psychotic patients in emergency settings 6
• In a prospective observational study of 278 patients with acute psychosis and agitation in emergency rooms, olanzapine demonstrated significant improvements in agitation rating scales with a low incidence of adverse events 6

Remember that the goal of treatment is to rapidly control agitation while minimizing adverse effects. Always assess for orthostatic hypotension before administering repeat doses, and be particularly cautious when using olanzapine IM with benzodiazepines due to potential serious adverse outcomes.