Is Zydis (olanzapine) appropriate for use as needed (prn) for psycho-somatic catatonia and shaking?

Olanzapine Zydis for PRN Use in Psychosomatic Catatonia and Shaking

Olanzapine Zydis (orally disintegrating tablet) can be used PRN for acute catatonia with agitation, but benzodiazepines remain the first-line treatment for catatonia itself, while olanzapine is better suited for managing severe psychomotor agitation or when benzodiazepines fail. 1

Treatment Algorithm for Catatonia with Agitation

First-Line Approach

• Start with benzodiazepines as the primary treatment for catatonia, specifically lorazepam 1-2 mg IV/SC/PO as the gold standard 1, 2
• Benzodiazepines typically produce symptom reduction within 24-72 hours in non-schizophrenic catatonia 3
• If lorazepam is unavailable, midazolam 2.5-5 mg IV/SC can be used as an alternative 1, 2

Role of Olanzapine Zydis

• Olanzapine 2.5-5 mg can be given PRN (stat dose) for severe psychomotor agitation that accompanies catatonia, particularly when the patient poses risk to self or others 1
• The orally disintegrating tablet (Zydis/ODT) formulation is specifically mentioned in guidelines as available and useful for patients who cannot swallow or are refusing oral medication 1
• Start with 2.5 mg in older or frail patients; standard starting dose is 2.5-5 mg 1

When to Use Olanzapine in Catatonia

Use olanzapine when:

• Benzodiazepines alone provide insufficient control of severe agitation 4
• The patient has schizophrenia with catatonic features (which is notoriously resistant to benzodiazepine monotherapy) 4
• Combination therapy may be needed: emerging evidence supports combining lorazepam with olanzapine for schizophrenia-related catatonia 4

Critical cautions:

• Conventional antipsychotics can worsen or induce malignant catatonia and should be avoided 5
• The safety profile of atypical antipsychotics like olanzapine in catatonia remains somewhat controversial, with case reports of both benefit and potential worsening 5, 3
• One case report documented a fatal malignant catatonia possibly associated with olanzapine 10 mg daily, though causality was unclear 5

Specific Dosing for PRN Use

For acute agitation with catatonia:

• Olanzapine Zydis 2.5-5 mg PO stat (single dose) 1
• Can repeat dosing, but scheduled dosing should only be used for persistent symptoms and for the shortest duration possible 1
• Reduce dose in elderly patients and those with hepatic impairment 1

For the "shaking" component:

• If tremor represents akathisia or extrapyramidal symptoms from prior antipsychotic use, olanzapine may actually help as it has lower EPS risk than typical antipsychotics 1
• If tremor is parkinsonian in nature from catatonia itself, benzodiazepines are preferred 1

Safety Considerations

Important warnings with olanzapine:

• May cause drowsiness and orthostatic hypotension (monitor blood pressure) 1
• Fatal respiratory depression and oversedation reported when combined with benzodiazepines - use extreme caution if combining 1
• Metabolic effects with long-term use (less relevant for PRN dosing) 1
• Use lower doses (2.5 mg) in elderly patients due to increased mortality risk in dementia-related psychosis 1

Clinical Decision Framework

Choose benzodiazepines alone when:

• First presentation of catatonia without severe agitation 2, 3
• No underlying psychotic disorder 5

Add olanzapine Zydis PRN when:

• Severe agitation requires rapid control alongside catatonia treatment 1
• Benzodiazepines provide inadequate symptom control after 24-48 hours 4
• Patient has schizophrenia with catatonic features 4

Avoid olanzapine and consider ECT when:

• Malignant catatonia is suspected (fever, autonomic instability, rigidity) 5
• No response to benzodiazepines after 72 hours 5
• Life-threatening presentation 5

Common Pitfalls

• Do not use typical antipsychotics (haloperidol, chlorpromazine) for catatonia - they can precipitate malignant catatonia 5
• Do not assume all "shaking" is the same - differentiate between catatonic rigidity, parkinsonian tremor, akathisia, and anxiety-related tremor 1
• If combining olanzapine with benzodiazepines, start with lowest doses and monitor closely for respiratory depression 1
• Do not continue scheduled olanzapine long-term without reassessing need - PRN use is safer 1