From the Guidelines
The best antipsychotic for cancer-related psychosis is typically olanzapine (Zyprexa), starting at 2.5-5mg orally daily and titrating as needed up to 10mg daily. This recommendation is based on the most recent and highest quality study available, which compared the efficacy and safety of different antipsychotics in cancer patients with delirium 1. Olanzapine is preferred because it has antiemetic properties, minimal extrapyramidal side effects, and can be administered orally, sublingually, or intramuscularly.
Some key points to consider when using antipsychotics in cancer patients include:
- Starting with lower doses than typically used in psychiatric settings due to potential increased sensitivity
- Monitoring for QT prolongation (especially with IV haloperidol)
- Being aware that these medications may lower the seizure threshold
- Individualizing treatment duration based on symptom resolution, with gradual tapering when appropriate
- Considering the patient's specific symptoms, comorbidities, and medication interactions with cancer treatments
Haloperidol (Haldol) is an alternative option, starting at 0.5-1mg orally or parenterally every 8-12 hours, particularly useful in delirium 1. For patients who cannot tolerate olanzapine or haloperidol, quetiapine (Seroquel) starting at 25mg daily and titrating up to 100-200mg daily may be considered 1. It's essential to note that the choice of antipsychotic should be tailored to the individual patient's needs and circumstances.
In terms of specific symptoms, the study by Hui et al. found that lorazepam and haloperidol combination therapy was effective in reducing agitation in cancer patients with delirium 1. However, the use of benzodiazepines should be approached with caution, especially in older patients or those with cognitive impairment, due to the risk of decreased cognitive performance 1.
Overall, the goal of antipsychotic treatment in cancer-related psychosis is to improve symptoms, reduce distress, and enhance quality of life, while minimizing potential side effects and interactions with other medications.
From the Research
Antipsychotic Options for Cancer-Related Psychotic Episodes
- Olanzapine has been studied as a potential treatment for cancer-related psychotic episodes, with some evidence suggesting its effectiveness 2, 3, 4, 5, 6.
- A case report found that olanzapine 2.5 mg/day was effective in treating a patient with metastatic breast cancer and a psychotic disorder 2.
- A preliminary study found that subcutaneous olanzapine was safe and tolerable in patients with advanced cancer and hyperactive or mixed delirium 3.
- A study comparing the efficacy of different antipsychotics for delirium treatment in patients with cancer found that olanzapine was effective, particularly in patients with a long half-life or multiacting receptor-targeted antipsychotics 4.
- A randomized controlled trial found that olanzapine improved appetite, weight, and quality of life in patients with locally advanced or metastatic cancer treated with chemotherapy 5.
- A phase III randomized clinical trial compared the efficacy and tolerability of olanzapine with haloperidol for the treatment of delirium in hospitalized patients with advanced cancer, and found that olanzapine had a better safety profile, although the difference was not statistically significant 6.
Comparison of Antipsychotics
- Haloperidol is a common treatment for delirium, but it may have more side effects than olanzapine 6.
- Olanzapine has been found to have a better safety profile than haloperidol in some studies 6.
- Risperidone and quetiapine are other antipsychotics that have been studied for delirium treatment in patients with cancer, but the evidence is limited 4.
- Mirtazapine has been found to have no nutritional or anthropometric gain in patients with cancer and anorexia 5.
Considerations for Treatment
- The choice of antipsychotic should be based on the individual patient's needs and medical history 6.
- The efficacy and safety of antipsychotics for delirium treatment in patients with cancer should be carefully considered, and treatment should be targeted and judicious 6.
- Further research is needed to fully understand the effectiveness of different antipsychotics for cancer-related psychotic episodes 3, 4, 6.