Is olanzapine (an atypical antipsychotic) a suitable choice for patients with a history of seizures?

Olanzapine Use in Patients with Seizure History

Olanzapine should be used with caution in patients with a history of seizures as it can lower the seizure threshold, but it is generally a safer option compared to clozapine among atypical antipsychotics. 1, 2

Seizure Risk with Olanzapine

• Olanzapine has been associated with seizures in 0.9% of patients during premarketing testing, with several confounding factors potentially contributing to these events 1
• The FDA label specifically warns that olanzapine should be used cautiously in patients with a history of seizures or conditions that potentially lower the seizure threshold 1
• Case reports have documented olanzapine-induced seizures even at subtherapeutic doses, particularly in patients with additional risk factors 3, 2
• Olanzapine shares pharmacological similarities with clozapine, which has a known high risk of dose-dependent seizures 4

Risk Factors for Olanzapine-Induced Seizures

• Advanced age (elderly patients) 3
• History of stroke or previous seizures 3
• Cognitive impairment or dementia 3, 4
• Combination therapy with other antipsychotics or medications that lower seizure threshold 3, 5
• Rapid dose increases 1

Recommendations for Patients with Seizure History

• Consider alternative antipsychotics with potentially lower seizure risk if appropriate for the patient's condition 2
• If olanzapine is clinically indicated:
  • Start with lower doses and titrate slowly 1, 3
  • Monitor closely for signs of seizure activity, especially during initial treatment and dose adjustments 1
  • Avoid combining with other medications that lower seizure threshold when possible 5
  • Consider EEG monitoring in high-risk patients 2, 4

Alternative Antipsychotic Options

• Haloperidol may be a safer option for patients with seizure history, as demonstrated in case reports where patients who experienced olanzapine-induced seizures were successfully switched to haloperidol without seizure recurrence 2, 4
• For patients requiring an atypical antipsychotic, quetiapine may be considered as it has a relatively favorable profile regarding seizure risk 6, 7

Monitoring and Management

• Regular clinical monitoring for seizure activity is essential when using olanzapine in patients with seizure history 1
• If seizures occur, discontinuation of olanzapine should be considered 1, 2
• Documentation of suspected side effects is crucial 8
• Consider consultation with neurology for patients with a history of seizures who require antipsychotic treatment 9

Important Precautions

• The risk of seizures with olanzapine increases in a dose-dependent manner 1
• Conditions that lower seizure threshold may be more prevalent in elderly populations (65 years or older) 1
• Olanzapine is not approved for treatment of patients with Alzheimer's disease, where the risk of adverse effects including seizures may be higher 1