Olanzapine atypical antipsychotic medications

First, initiate and/or optimize mood-stabilizing medication lithium3 or valproate3 or atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone)... 

Nevertheless, some atypical antipsychotic drugs, such as clozapine and olanzapine, have been linked to substantial weight gain, hyperlipidemia and type II diabetes, a new range of medically serious side-effects. 

First, optimize current mood stabilizer or initiate mood-stabilizing medication lithium,0 valproate,0 or carba-mazepine0 Consider adding a benzodiazepine (lorazepam or clonazepam) for short-term adjunctive treatment of agitation or insomnia if needed Alternative medication treatment options carbam-azepine0 if patient does not respond or tolerate, consider atypical antipsychotic (e.g., olanzapine, quetiapine, risperidone) or oxcarbazepine. 

Quetiapine (Seroquel). Another atypical antipsychotic, quetiapine has also been approved by the FDA for the treatment of acute mania. It is usually administered twice daily at doses of 150-750mg/day. Like its counterparts, quetiapine is a well-tolerated medication. Its common side effects are drowsiness, dizziness, and headache. It causes less weight gain than olanzapine or clozapine but more than ziprasidone or aripiprazole. Quetiapine also does not cause agranulocytosis nor does it increase the risk of seizures. It can occasionally cause mild changes in liver function tests, but these usually return to normal even if the patient continues taking quetiapine. 

Choice of a Mood Stabilizer. With the advance of atypical antipsychotics and an ever-expanding list of anticonvulsants, the number of medications reported to treat acute mania and hypomania continues to grow. In fact, all of the atypical antipsychotics, olanzapine, quetiapine, risperidone, ziprasidone, and aripiprazole have FDA approval for the treatment of acute mania. Long-term protection against future episodes of illness has also been demonstrated with several of these agents, which can influence the choice of initial therapy. 

Atypical antipsychotics may be helpful in managing the delusions and agitated behavior that can accompany dementia. These medications, include risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), and olanzapine (Zyprexa). All antipsychotics, typical and atypical, appear to increase the risk of death in patients with dementia and psychosis. This appears as a warning in the package inserts of the newer drugs. A prudent approach is to discuss this risk with the caregiver, use the lowest effective dose, and monitor for effectiveness. 

We prefer low doses of atypical antipsychotics as a first-line treatment. In this way, the threat of extrapyramidal symptoms is largely avoided without having to use a second anticholinergic medication to offset antipsychotic side effects. Risperidone 0.25-0.5mg/day, olanzapine 2.5mg/day, quetiapine 25mg/day, ziprasidone 20mg/day, or aripiprazole 2.5-5mg/day are reasonable starting doses. The typically higher doses used to treat schizophrenia are usually not necessary. 

Antipsychotic medications (atypical [eg, olanzapine, clozapine]) Isoniazid... 

In the Expert Consensus survey (Rush and Frances, 2000), respondents were asked to rate which classes of medication may be helpful for treating patients with severe and persistent physical aggression and those who destroyed property. The atypical antipsychotics were rated most highly, followed by anticonvulsant/ mood stabilizer. These were followed (with much lower priority) by antidepressants and beta-blockers. Among the atypical antipsychotics, risperidone was rated most highly, followed by olanzapine others had much lower ratings. Divalproex or valproic acid and carbamazepine were rated highest of the mood stabi-... 

In the Expert Consensus survey (Rush and Frances, 2000) the expert clinicians rated newer atypical antipsychotics highest for treatment of schizophrenic patients who are compliant with medication. Risperidone was rated highest of the atypicals, followed by olanzapine. In the case of patients with numerous failed trials with other antipsychotics, the experts voted for clozapine. For patients noncompliant with oral medication, respondents endorsed long-acting depot antipsychotics. Once again, these were impressions based on personal clinical experiences rather than hard empirical data. 

With regards to the effects of antipsychotic medications on muscarinic and nAChR in the brain, only olanzapine resulted in a temporary increase of muscarinic binding sites in a long-term study of different typical and atypical antipsychotics (Terry et al., 2006). This result is in accordance with in vitro (Bymaster et al., 1996 Schotte et al., 1996) and in vivo (Raedler et al., 2000) studies showing that olanzapine has considerable affinity to mAChRs. 

Although presently only lithium, valproic acid/divalproex, and several atypical antipsychotics have been approved by the FDA as treatments for acute mania, clinicians prescribe a number of other medications as well for patients in the manic phase (Table 3.20). The strength of the data justifying their use varies, with the strongest evidence occurring with lithium and followed by atypical antipsychotics (aripiprazole, olanzapine, etc.). 

A new class of medications has been recently introduced for the treatment of mania the atypical antipsychotics. These medications, commonly used for the treatment of schizophrenia and other psychoses, have been found to have powerful antimanic effects. Olanzapine was the first atypical antipsychotic approved for this purpose by the FDA, and others in this class soon followed. 

Atypical or nontraditional antipsychotic medications have fewer movement symptoms than the typical antipsychotics. Examples of these medications include (see Table 7.3) clozapine (Clozaril), risperidone (Risperdal), sertindole (Serlect), olanzapine (Zyprexa) and quentiapine (Seroquel). These medications have gained popularity because they appear to have lower EPS proflles and they help individuals to think more clearly and follow directions better, to learn new facts and master new skills, and to interpret emotion more accurately (Lambert, 1998). 

When an antipsychotic is needed, we prefer using one of the newer atypical agents olanzapine, ziprasidone, risperidone, quetiapine, or aripiprazole. Each of these medications reliably reduces agitation and is well tolerated. In particular, they decrease the potential for acute dystonic reactions and tardive dyskinesia caused by the typical antipsychotics. Both ziprasidone and olanzapine are now available in an injectable form that is very rapidly acting and effective in this setting. 

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