What should I do for a patient on Lybalvi (olanzapine and samidorphan) 15 mg experiencing anxiety and hypertension?

Management of Hypertension in a Patient on Lybalvi (Olanzapine/Samidorphan)

For a patient experiencing anxiety and hypertension while on Lybalvi 15 mg, the most appropriate approach is to address the hypertension with antihypertensive medication while considering the potential drug interactions with olanzapine/samidorphan, particularly focusing on orthostatic hypotension risk.

Assessment of Hypertension

• Confirm hypertension by taking at least two blood pressure readings and averaging them, as per international guidelines 1
• If office BP is ≥140/90 mmHg, this confirms hypertension, especially if home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg 1
• Use a validated BP measuring device with appropriate cuff size for accurate readings 1

Considerations with Lybalvi (Olanzapine/Samidorphan)

• Lybalvi contains olanzapine which may induce orthostatic hypotension associated with dizziness, tachycardia, bradycardia, and in some patients, syncope, especially during initial dose-titration 2
• Orthostatic hypotension was recorded in ≥20% of patients treated with oral olanzapine in clinical studies 2
• Lybalvi should be used with particular caution in patients with known cardiovascular disease, cerebrovascular disease, and conditions predisposing to hypotension 2

Treatment Approach

First-line Management:

• Start with lifestyle interventions including reduced salt intake, increased physical activity, weight management, and limited alcohol consumption 1
• For pharmacological management, consider:
  • Low-dose ACE inhibitor or ARB as first-line therapy for non-black patients 1
  • For black patients, consider low-dose ARB with dihydropyridine calcium channel blocker (DHP-CCB) or thiazide/thiazide-like diuretic 1

Special Considerations for Psychiatric Patients:

• Beta-blockers (except metoprolol) should be considered if the patient has drug-induced tachycardia from antipsychotic medications 1
• RAS inhibitors (ACE inhibitors or ARBs) and diuretics are preferred in patients with psychiatric disorders due to fewer pharmacological interactions with antidepressants 1
• Use calcium channel blockers and alpha-1 blockers with caution due to potential orthostatic hypotension risk, which could compound similar effects from olanzapine 1, 2

Anxiety Management:

• Consider benzodiazepines for short-term management if anxiety is contributing significantly to blood pressure elevation 3, 4
• Studies have shown benzodiazepines can effectively lower blood pressure in patients with excessive hypertension and anxiety 3
• However, use caution with benzodiazepines as concomitant administration with olanzapine can lead to excessive sedation and cardiorespiratory depression 2

Monitoring and Follow-up

• Target BP reduction of at least 20/10 mmHg with goal of <130/80 mmHg 1
• Monitor BP control with goal to achieve target within 3 months 1
• Watch for signs of orthostatic hypotension (dizziness upon standing, lightheadedness) 2
• Monitor for potential drug interactions between antihypertensives and Lybalvi 1

Cautions and Pitfalls

• Avoid abrupt discontinuation of Lybalvi as this could lead to withdrawal symptoms 2
• Be aware that patients on Lybalvi who are also taking opioid medications (including buprenorphine) may experience precipitated opioid withdrawal due to the samidorphan component 5, 6
• If BP remains uncontrolled despite optimal therapy, consider referral to a specialist with hypertension expertise 1
• For patients with resistant hypertension (BP >140/90 mmHg despite three medications including a diuretic), consider adding spironolactone as a fourth agent if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m² 1

Medication Adjustments

• If orthostatic hypotension occurs, consider more gradual titration of antihypertensive medications 2
• Simplify medication regimen with once-daily dosing and single-pill combinations to improve adherence 1
• Individualize BP targets based on frailty, especially in elderly patients 1