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Out of the Pipeline


Intramuscular olanzapine: Treating acute agitation in psychosis and bipolar mania

Vol. 3, No. 5 / May 2004

Oral atypical antipsychotics are given to treat a variety of psychiatric illnesses. Intramuscular (IM) preparations of atypicals are increasingly becoming available for emergency use, such as treating acute agitation.

The FDA has approved IM olanzapine for treating acute agitation associated with schizophrenia and bipolar type I mania.

How it works

As with the agent’s oral formulations (tablets, capsules, wafers), IM olanzapine is primarily an antagonist at serotonergic (5-HT2A) and dopaminergic (D2) receptors. Olanzapine is about twice as active at 5-HT2A compared with D2 receptors, which may underlie the agent’s efficacy as an antipsychotic and mood stabilizer without significant extrapyramidal effects.

Olanzapine also shows primarily antagonistic binding affinity at the 5-HT2B/2C, D1/D3/D4/D5, muscarinic, histamine H1 and alpha1-adrenergic receptors. 1 This binding profile is comparable to that of clozapine and predicts a similar clinical response.

Pharmacokinetics

On most pharmacokinetic measures, IM olanzapine is nearly identical to its oral formulations, allowing easy comparison when switching to oral dosing as the patient improves. 2

Plasma clearance (linear pharmacokinetics), half-life (approximately 30 hours), and volume of distribution are similar for IM and oral olanzapine. Maximum plasma concentrations after one, two, or three 10-mg injections given over 24 hours were similar to steady-state concentrations after daily administration of oral olanzapine, 20 mg.

The one key difference between IM and oral olanzapine is rate of absorption, which influences onset of action. IM olanzapine generally reaches maximum concentration in 15 to 45 minutes, compared with 4 hours after an oral dose. This rapid peak absorption could prove valuable in the first hour of a psychiatric emergency.

Efficacy

Three double-blind, randomized, placebo and active comparator-controlled studies demonstrated IM olanzapine’s safety and efficacy for treating acute agitation in patients with schizophrenia and bipolar type I mania. A fourth study gauged its efficacy in treating acute agitation in dementia.

Schizophrenia. In a study of 285 patients, 3 IM olanzapine, 10 mg, was significantly more effective in reducing agitation than IM haloperidol, 7.5 mg, and IM placebo 15, 30, and 45 minutes after injection. Agitation was measured with the Positive and Negative Symptom Scale-Excited Component (PANSS-EC), Agitated Behavior Scale, and Agitation-Calmness Evaluation scale. Olanzapine and haloperidol were similar in efficacy 1 and 2 hours after injection, and both were more effective than placebo.

In another study, 4 270 acutely agitated inpatients with schizophrenia received 1 to 3 IM injections of olanzapine (2.5, 5, 7.5, or 10 mg), haloperidol (7.5 mg), or placebo. The higher the olanzapine dose, the greater the PANSS-EC score reduction 2 hours after the first injection. Olanzapine was more effective than haloperidol on some agitation measures at 7.5 and 10 mg, and olanzapine was significantly more effective than haloperidol 24 hours post-injection, based on Agitated Behavior Scale scores. 4 Both agents were similarly effective 2 hours after injection.

Bipolar type I mania. Agitated patients (N = 201) received 1 to 3 IM injections of olanzapine (10 mg for the first two injections, 5 mg for the third), lorazepam (2 mg first two, 1 mg third), or placebo.

Two hours after the first injection, agitation was more greatly reduced within the olanzapine group than in the lorazepam or placebo groups based on PANSS-EC, Agitated Behavior Scale, and Agitation-Calmness Evaluation Scale scores. At 24 hours, olanzapine was more effective than placebo but similar in efficacy to lorazepam. 5

Table

IM olanzapine: Fast facts

Drug brand name:
Zyprexa IntraMuscular

Class
Atypical antipsychotic

FDA-approved indication:
Acute agitation associated with bipolar type I mania and schizophrenia

Approval date:
March 29, 2004

Manufacturer:
Eli Lilly and Co.

Dosing form:
10 mg

Dosing recommendations:
10 mg for adults with schizophrenia and bipolar type I mania (5 mg ages 65 and older); 2.5 mg for patients who are debilitated, predisposed to hypotensive reactions, or sensitive to olanzapine. Consider 5- or 7.5-mg doses if clinical factors warrant, such as reduced clearance/slower metabolism in older, nonsmoking women.

Dementia. A total of 272 patients with Alzheimer’s dementia, mixed dementia, or both received IM olanzapine (2.5 mg or 5 mg), IM lorazepam (1 mg), or IM placebo. The 5-mg olanzapine dose significantly reduced agitation 30 minutes post-injection, whereas lorazepam separated from placebo 60 minutes post-injection based on PANSS-EC scores. At 24 hours, both olanzapine doses were more effective than lorazepam or placebo.6

Tolerability

No clinically significant side effects have been reported with IM olanzapine. Incidence of extrapyramidal symptoms and QTc interval changes has been similar to that reported with placebo. Most studies have reported little change in vital signs, although a 7-bpm increase in heart rate and 5- to 7-mm Hg decrease in systolic blood pressure have been noted (Eli Lilly and Co., data on file).

Differences in treatment-emergent somnolence rates among patients receiving IM olanzapine (4% to 13%) and placebo (3% to 6%) were not statistically significant. Analyses of patients without treatment-emergent somnolence suggest that IM olanzapine retains a specific calming effect (as opposed to nonspecific sedation). 7

Clinical implications

IM olanzapine offers psychiatrists a fast-acting option for treating agitation in patients with schizophrenia and bipolar type I mania. Its onset of action, measurable at 15 minutes post-injection, should prove valuable in the critical first hour of emergency psychiatric treatment. IM olanzapine’s efficacy and safety profile compare favorably with those of IM haloperidol and IM lorazepam.

IM olanzapine has shown safety and efficacy in treating agitation associated with dementia. Though the FDA has not approved this indication, the agent will likely be used for this purpose.

The only other fast-acting, injectable atypical antipsychotic—IM ziprasidone—is indicated for treatment of acute agitation in schizophrenia. Head-to-head comparisons between IM olanzapine and IM ziprasidone have not been conducted.

Clinical use and research will determine IM olanzapine’s role in treating patients with severe agitation (such as nonconsenting patients), those who are medically compromised, or patients in drug-induced psychotic states.

Related resources

Drug brand names

  • Clozapine • Clozaril
  • Haloperidol • Haldol
  • Lorazepam • Ativan
  • Olanzapine • Zyprexa
  • Ziprasidone • Geodon

Disclosure

Dr. Battaglia is a consultant to and speaker for Eli Lilly and Co.

References

1. Bymaster FP, Calligaro DO, Falcone JF, et al. Radioreceptor binding profile of the atypical antipsychotic olanzapine. Neuropsychopharmacology 1996;14:87-96.

2. FDA Psychopharmacological Drugs Advisory Committee. Briefing document for Zyprexa (intramuscular olanzapine), February 13, 2001.

3. Wright P, Birkett M, David SR, et al. Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia. Am J Psychiatry 2001;158:1149-51.

4. Breier A, Meehan K, Birkett M, et al. A double-blind, placebo-controlled dose-response comparison of intramuscular olanzapine and haloperidol in the treatment of acute agitation in schizophrenia. Arch Gen Psychiatry 2002;59:441-8.

5. Meehan K, Zhang F, David S, et al. A double-blind, randomized comparison of the efficacy and safety of intramuscular injections of olanzapine, lorazepam, or placebo in treating patients diagnosed with bipolar mania. J Clin Psychopharmacol 2001;21:389-97.

6. Meehan KM, Wang J, David S, et al. Comparison of rapidly acting intramuscular olanzapine, lorazepam, and placebo: A double blind, randomized study in acutely agitated patients with dementia. Neuropsychopharmacology 2002;26:494-504.

7. Battaglia J, Lindborg S, Alaka K, et al. To sleep or not to sleep? Calming versus sedative effects of intramuscular olanzapine in agitated patients. Am J Emerg Med 2003;21:192-8.

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