What is the recommended dose of Olanzapine (an atypical antipsychotic) for the treatment of acute psychosis?

From the Guidelines

For acute psychosis, the recommended initial target dose of olanzapine is 7.5-10.0 mg/day. This dose is based on the most recent and highest quality study available, which suggests that low doses of antipsychotic medication are preferred to minimize the risk of extrapyramidal side-effects and encourage future adherence to medication 1. The study also notes that the dose of antipsychotic should be increased only at widely spaced intervals (after initial titration, usually 14–21 days) if the response has been inadequate, and then only within the limits of sedation and the emergence of extrapyramidal side-effects.

Some key points to consider when initiating olanzapine treatment for acute psychosis include:

• Starting with a low dose to minimize side effects and improve adherence
• Gradually increasing the dose as needed and tolerated
• Monitoring for extrapyramidal side-effects and sedation
• Considering the patient's overall health and medical history before initiating treatment
• Providing emotional support and practical advice to families, who are often in crisis at the point of initiation of treatment

It's also important to note that olanzapine works by blocking multiple neurotransmitter receptors, particularly dopamine D2 and serotonin 5-HT2A receptors, which helps reduce psychotic symptoms by normalizing excessive dopamine signaling in the mesolimbic pathway. However, the exact mechanism of action is not as important as the clinical efficacy and safety of the medication, which is supported by the study 1.

In terms of specific treatment guidelines, the study suggests that treatment should commence prior to the development of a crisis, such as self-harm, violence or aggression, and may be an appropriate alternative to in-patient admission 1. Additionally, in-patient care should ideally be provided in units that provide services targeting early psychosis, and families should be included in the assessment process and treatment plan.

From the FDA Drug Label

The trial summaries below focus on the following outcomes: PANSS total and/or BPRS total; BPRS psychosis cluster; PANSS negative subscale or SANS; and CGI Severity The results of the trials follow: (1) In a 6-week, placebo-controlled trial (n=149) involving 2 fixed olanzapine doses of 1 and 10 mg/day (once daily schedule), olanzapine, at 10 mg/day (but not at 1 mg/day), was superior to placebo on the PANSS total score (also on the extracted BPRS total), on the BPRS psychosis cluster, on the PANSS Negative subscale, and on CGI Severity (2) In a 6-week, placebo-controlled trial (n=253) involving 3 fixed dose ranges of olanzapine (5 ± 2.5 mg/day, 10 ± 2.5 mg/day, and 15 ± 2. 5 mg/day) on a once daily schedule, the 2 highest olanzapine dose groups (actual mean doses of 12 and 16 mg/day, respectively) were superior to placebo on BPRS total score, BPRS psychosis cluster, and CGI severity score; In this flexible-dose trial, olanzapine 2.5 to 20 mg/day (mean modal dose 12.5 mg/day, mean dose of 11. 1 mg/day) was more effective than placebo in the treatment of adolescents diagnosed with schizophrenia, as supported by the statistically significantly greater mean reduction in BPRS-C total score for patients in the olanzapine treatment group than in the placebo group

The recommended dose of olanzapine for acute psychosis is:

• 10 mg/day in adults, as shown in the first 6-week trial
• 2.5 to 20 mg/day in adolescents, with a mean modal dose of 12.5 mg/day Key points:
• The dose range for adults is 5 to 20 mg/day
• The dose range for adolescents is 2.5 to 20 mg/day
• The mean dose for adolescents is 11.1 mg/day 2

From the Research

Olanzapine Dose for Acute Psychosis

• The recommended dose of olanzapine for acute psychosis can vary, but studies have shown that doses ranging from 5 to 20 mg are well tolerated 3.
• A case series study found that olanzapine initiated at 15 to 20 mg/day was safe and effective for rapidly calming agitation in acutely agitated psychotic patients 3.
• Another study found that olanzapine, quetiapine, and risperidone had comparable effectiveness in early-psychosis patients, with mean modal prescribed daily doses of 11.7 mg for olanzapine 4.
• In the treatment of psychotic agitation, olanzapine has been shown to be as effective as haloperidol and better tolerated, with significant improvement in aggressive behavior and fewer extrapyramidal symptoms 5.

Key Findings

• Olanzapine doses of up to 20 mg/day have been used in the treatment of acute psychosis 3, 4.
• The medication has been shown to be effective in rapidly calming agitation in acutely agitated psychotic patients 3.
• Olanzapine has a more favorable side-effect profile compared to conventional antipsychotics, making it a suitable option for both short- and long-term treatment 6.
• The development of intramuscular formulations of olanzapine offers new treatment options for patients experiencing acute psychotic episodes 6.