What is the typical dose of olanzapine (atypical antipsychotic) for patients with bipolar depression?

Olanzapine Dosing for Bipolar Depression

For bipolar depression, olanzapine monotherapy should be initiated at 5-10 mg once daily, with a typical effective dose range of 5-20 mg/day and a mean dose of approximately 14 mg/day based on controlled trials. 1, 2, 3

Starting Dose

• Begin with 5-10 mg once daily for most adult patients with bipolar depression 1
• The FDA label specifies that olanzapine dosing for bipolar disorder should generally begin with 10 or 15 mg, though lower starting doses (5 mg) are appropriate for patients who are debilitated, elderly (≥65 years), or have predisposition to hypotensive reactions 1
• For adolescents with bipolar disorder, start with 2.5-5 mg once daily, targeting 10 mg/day 1

Effective Dose Range

• The therapeutic dose range is 5-20 mg/day for bipolar depression 1, 2, 3
• In the largest placebo-controlled trial of olanzapine monotherapy for bipolar I depression (n=343), patients received flexible dosing of 5-20 mg/day and demonstrated significantly greater improvement in depressive symptoms compared to placebo 2
• A second randomized controlled trial found the mean final dose was 14.4 mg/day, with response rates of 50% and remission rates of 35.3% (versus 20.6% and 11.8% for placebo, respectively) 3

Dose Titration

• Dosage adjustments should occur at intervals of not less than 24 hours when clinically indicated 1
• When dose changes are necessary, use increments or decrements of 5 mg 1
• Doses above 10 mg/day were not demonstrated to be more efficacious than 10 mg/day in some studies, though individual patients may benefit from higher doses up to 20 mg/day 1

Maximum Dose

• Do not exceed 20 mg/day - olanzapine is not indicated for use above this dose, and safety/efficacy above 20 mg/day has not been established 1

Special Populations

• Elderly patients (≥65 years): Start with 5 mg once daily, or 2.5 mg if frail or with hepatic impairment 4, 1
• Adolescents (13-17 years): Start with 2.5-5 mg once daily, with a target of 10 mg/day (mean modal dose in trials was 10.7 mg/day for bipolar mania) 1

Combination Therapy Consideration

• The FDA has approved olanzapine combined with fluoxetine specifically for bipolar depression in adults 5, 6, 7
• This combination demonstrated superior efficacy to olanzapine monotherapy or lamotrigine in treating acute bipolar depression 6, 7
• However, when using olanzapine monotherapy (as asked), the dosing remains 5-20 mg/day 2, 3

Critical Safety Monitoring

• Monitor weight, fasting glucose, and lipid panels - olanzapine causes significant metabolic side effects including weight gain (mean weight increase and elevations in cholesterol, triglycerides, and LDL) 2, 3
• Approximately 40% of patients experience clinically significant weight gain 4
• Monitor for orthostatic hypotension, especially during initial titration 4
• Common side effects include somnolence, dry mouth, dizziness, and increased appetite 8

Practical Algorithm

1. Start at 5-10 mg once daily (use 5 mg for elderly/debilitated patients) 1
2. Assess response after 1 week - most patients respond within the first week of treatment 2
3. If inadequate response, increase by 5 mg increments at intervals of at least 24 hours 1
4. Target dose: 10-15 mg/day (mean effective dose in trials was 14.4 mg/day) 3
5. Maximum dose: 20 mg/day - do not exceed 1
6. Monitor metabolic parameters at baseline, week 4, and every 3 months thereafter 4