What is the recommended tapering schedule for discontinuing Zyprexa (olanzapine) 10 mg in an inpatient setting?

Tapering Olanzapine (Zyprexa) 10 mg in an Inpatient Setting

A gradual taper of olanzapine 10 mg should be implemented with reductions of 2.5 mg every 1-2 weeks, monitoring closely for withdrawal symptoms and adjusting the taper rate based on patient response.

General Tapering Principles

• For antipsychotics like olanzapine, a decrease of approximately 10% of the original dose per week is a reasonable starting point, though this should be adjusted based on individual patient response 1
• For patients who have been on olanzapine for longer durations, slower tapers might be better tolerated 1
• Tapering should be slow enough to minimize withdrawal symptoms, which may include anxiety, insomnia, nausea, dizziness, irritability, and tremor 1

Recommended Tapering Schedule for Olanzapine 10 mg

• Week 1-2: Reduce from 10 mg to 7.5 mg daily 2
• Week 3-4: Reduce from 7.5 mg to 5 mg daily 2
• Week 5-6: Reduce from 5 mg to 2.5 mg daily 2
• Week 7-8: Reduce from 2.5 mg to 1.25 mg daily (if available, or alternate days) 2
• Week 9-10: Discontinue 2

Monitoring During Taper

• Assess for withdrawal symptoms after each dose reduction before proceeding to the next step 1
• Monitor for signs of psychosis relapse, which may be difficult to distinguish from withdrawal symptoms 2
• If severe withdrawal symptoms occur, return to the previous well-tolerated dose and slow the taper further 1

Managing Withdrawal Symptoms

• Common withdrawal symptoms include anxiety, insomnia, nausea, dizziness, irritability, and tremor 1
• For insomnia, short-term use of non-benzodiazepine sleep aids may be beneficial 1
• Consider adjunctive medications to manage specific withdrawal symptoms as needed 1

Special Considerations

• The inpatient setting provides an ideal environment for close monitoring during the initial phases of tapering 3
• PET imaging demonstrates a hyperbolic relationship between doses of antipsychotic and D2 receptor blockade, suggesting smaller reductions as the dose decreases 2
• Final doses before complete cessation may need to be very small to prevent a large decrease in D2 blockade when stopped 2
• Patients switched to another antipsychotic with immediate discontinuation of olanzapine may show an increase in symptom severity in the first week 4

Potential Pitfalls to Avoid

• Avoid abrupt discontinuation, which increases risk of withdrawal symptoms and relapse 1, 4
• Do not use a "one-size-fits-all" approach; be prepared to adjust the tapering schedule based on individual response 1
• Recognize that adaptations to antipsychotic exposure can persist for months after stopping the medication 2
• Sudden cessation is inappropriate and may lead to withdrawal symptoms similar to those seen with other centrally acting medications 3

Follow-up After Discontinuation

• Continue close monitoring for at least 3-6 months after complete discontinuation to assess for relapse 2
• If symptoms re-emerge, consider restarting at the last effective dose 1
• Document the patient's response to the taper to guide future treatment decisions 3