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Zyprexa Olanzapine Withdrawal

Withdrawal off Zyprexa must be done slowly. A to percent reduction of each dosage can be done but the last 2 reductions of the medication should be by only 5%.

Reduce the Olanzapine every 2 weeks by 10% during the withdrawal period. Except the last two reductions. Those need to be at 5% and it is advised to only ruduce when you are feeling very stable.

Send an email to Jim Harper and he will guide you through the Zyprexa withdrawal process.

If you are already in Olanzapine withdrawal click here

Zyprexa and its effectiveness for longer-term use, that is, for more than 4 weeks treatment of an acute episode, and for prophylactic use in mania, has not been systematically evaluated in controlled clinical trials.

Neuroleptic Malignant Syndrome (NMS) - A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs, including Zyprexa. Manifestations of (NMS) are hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac dysrhythmia), and acute renal failure.

Tardive Dyskinesia - A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with Zyprexa. The risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of Zyprexa increases.
There are no known treatments for tardive dyskinesia.

Orthostatic Hypotension (Lowered blood pressure when a person changes from a setting to an erect position) - Zyprexa may induce orthostatic hypotension associated with dizziness, tachycardia, and in some patients, syncope, especially during the initial dose-titration period. Zyprexa should be used with particular caution in patients with known cardiovascular disease, cerebrovascular disease, and conditions which would predispose patients to hypotension.
Seizures - Seizures during premarketing test showed 22 of 2500 people developed seizures.

Potential for Cognitive and Motor Impairment - Sleepiness, unnatural drowsiness, was a commonly reported adverse event associated with Zyprexa treatment, occurring at an incidence of 26%. Since Zyprexa has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles.

• "On May 3, 2002, Britain's Medicines Control Agency warned that several patients taking Eli Lilly's top selling drug Zyprexa (used to treat schizophrenia) had developed diabetes-related complications. In the Medicine Control Agency's Current Problems newsletter, the regulatory body said that the antipsychotic drug "can adversely affect blood glucose."

• "Forty reports "of hyperglycemia (elevated blood sugar), diabetes mellitus, or exacerbation of diabetes have been received in the UK. Four were associated with ketoacidosis and/or coma including one with a fatal outcome," according to the newsletter. "The precise mechanism of this suspected adverse drug reaction has not yet been elucidated and is currently being investigated further."

• "This follows an emergency report issued in April 2002 by the Japanese Health and Welfare Ministry to Eli Lilly Japan KK concerning side effects of Zyprexa after the deaths of two diabetic users of the drug. It said seven other patients had lost consciousness or become comatose after taking the drugs in the last 10 months. The Japanese Ministry said no new diabetes patients should be treated with the drug and ordered Eli Lilly to warn doctors to closely monitor diabetics already on the medication."
• "A paper written in late 2001 in the Journal of Clinical Psychiatry reports the FDA has been alerted 19 case reports of diabetes associated with the use of Zyprexa. Of the 19 patients seven had newly diagnosed hyperglycemia. The sugar disorder developed within a week of taking Zyprexa in two patients and within six months for eight others. One patient ultimately died of necrotizing pancreatitis, a condition in which cells in the pancreas die.

• "Personal injury attorneys are expected to file up to 10 lawsuits this month against Eli Lilly alleging the drugmaker failed to adequately disclose “serious side effects” associated with its schizophrenia and acute bipolar mania drug Zyprexa (olanzapine), plaintiffs’ lawyers announced last week. The San Francisco-based firm Hersh & Hersh recently filed two lawsuits over the drug and is filing 30 more on behalf of individuals who claim the drug led to such illnesses as diabetes, hyperglycemia and pancreatitis."

Source: National Institute of Mental Health

"Researchers and clinical psychopharmacologists do not fully know what causes schizophrenia. Side effects of Zyprexa include slowing of voluntary movement, expressionless face, rigidity and tremor of arms and head, abnormal toxicity of muscle tissues, and restlessness."

Zyprexa Can Cause Diabetes -

Eli Lilly is now trying to get the FDA to approve diabetes medication
Could this be the scam of the century? Bring out Prozac, which has a diabetes side effect, then Zyprexa with the same side effect, they get approved a medication to treat the disease you created for millions?

If you or I did this, we would be thrown in jail.

New Drug Application for Exenatide Submitted to FDA for Type 2 Diabetes

June 30, 2004

Amylin Pharmaceuticals, Inc., (Nasdaq: AMLN) and Eli Lilly and Company (NYSE: LLY) today announced the submission of a New Drug Application (NDA) to the U.S. Food and Drug Administration (FDA) for regulatory approval of exenatide. Exenatide is the first in a new class of medicines known as incretin mimetics under investigation for the treatment of type 2 diabetes. In clinical trials, exenatide has demonstrated reductions in blood sugar and improvements in markers of beta cell function. Patients in exenatide studies also lost weight.

"The submission of the exenatide NDA is a significant milestone both for Amylin Pharmaceuticals and for our collaboration with Eli Lilly and Company," said Ginger Graham, president and CEO, Amylin Pharmaceuticals. "This NDA includes data on more than 1,800 subjects treated with exenatide. We believe the application provides the FDA with the necessary information to evaluate exenatide for use as a new therapeutic option for people living with type 2 diabetes."

"The rapid increase in the prevalence of diabetes and the need for innovative new treatments has never been more critical than it is today," said John C. Lechleiter, Ph.D., executive vice president of pharmaceutical operations, Eli Lilly and Company. "Many patients with type 2 diabetes are struggling to control their blood sugar and, even with current oral therapies, find that they cannot reach their treatment goals. If approved, we believe exenatide could offer an important and novel treatment option for people with type 2 diabetes."

The exenatide NDA is made up of three major components; chemistry and manufacturing, preclinical and clinical. The clinical component of the submission is based largely on 30-week data from three blinded pivotal trials of exenatide involving more than 1,400 patients who were unable to control their blood sugar on common oral therapies including metformin, sulfonylurea or a combination of both. The submission also includes 52-week open-label data from the extensions of these pivotal studies and from an additional open-label study. In the pivotal studies, exenatide demonstrated statistically significant, sustained reductions in average blood sugar levels as measured by hemoglobin A1c (A1C). Patients in these studies also demonstrated progressive reductions in weight, a secondary endpoint of the studies. The open-label studies demonstrated that the reductions in A1C were sustained through 52 weeks of treatment with average reductions of approximately 1.1 percent. Reductions in weight were also sustained through 52 weeks of treatment with average reductions of approximately eight pounds. In addition, the exenatide data showed improvements in beta cell function, as measured by HOMA-B and proinsulin to insulin ratios, and the restoration of first-phase insulin response, a fundamental response lost early in the development of type 2 diabetes. Exenatide was generally well tolerated across the pivotal trials. The most common adverse event reported was mild to moderate nausea, which occurred primarily at initiation of therapy.
Exenatide is formulated as a sterile, injectable product that, if approved, will be delivered by a pen delivery system.

About Diabetes

Diabetes affects an estimated 194 million adults worldwide1 and more than 18 million in the United States.2 Approximately 90-95 percent of those affected have type 2 diabetes, a disease in which the body does not produce enough insulin and the cells in the body do not respond normally to the insulin. According to the U.S. Center for Disease Control and Prevention’s National Health and Nutrition Examination Survey, approximately 60 percent of diabetes patients do not achieve target A1C levels with their current treatment regimen. According to the American Diabetes Association, patients with A1Cs above target are more likely to develop diabetes-related complications, such as kidney disease, blindness and heart disease.3

ZYPREXA
Olanzapine Tablets
ZYPREXA ZYDIS
Olanzapine Orally Disintegrating Tablets
ZYPREXA IntraMuscular
Olanzapine for Injection
DESCRIPTION
CONTRADICTIONS

ZYPREXA is contraindicated in patients with a known hypersensitivity to the product. For specific information about the contraindications of lithium or valproate, refer to the CONTRAINDICATIONS section of the package inserts for these other products.

WARNINGS

Hyperglycemia and Diabetes Mellitus – Hyperglycemia, in some cases extreme and associated with ketpacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics including ZYPRXA, Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population. Given these confounders the relationship between atypical antipsychotic use and hyperglycemia-related adverse events in not completely understood. However, epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse events in patients treated with the atypical antipsychotics. Precise risk estimates for hyperglycemia-related adverse events in patients treated with atypical antipsychotics are not available.

Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics should be monitored regularly for worsening of glucose control. Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment. Any patient treated with atypical antipsychotics should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness. Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics should undergo fasting blood glucose testing. In some cases, hyperglycemia has resolved when the atypical antipsychotic was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of the suspect drug.

Safety Experience in Elderly Patients with Dementia-Related Psychosis – In placebo-controlled clinical trials of elderly patients with dementia-related psychosis, the incidence of death in ZYPRXA-treated patients was significantly greater than placebo-treated patients (3.5% vs 1.5%, respectively). Risk factors that may predispose this patient population ot increased mortality when treated with ZYPRXA include age >80 years, sedation, concomitant use of benzodiazepines or presence of pulmonary conditions (e.g., pneumonia, with or without aspiration). ZYPRXA is not approved for the treatment of patients with dementia-related psychosis.

Cerebrovascula Adverse Events, Including Stroke, in Elderly Patients with Dementia -Cerebrovascular adverse events (e.g., stroke, transient ischemic attack), including fatalities, were reported in patients in trials of ZYPREXA in elderly patients with dementia-related psychosis. In placebo-controlled trials, there was a significantly higher incidence of cerebrovascular adverse events in patients treated with ZYPREXA compared to patients treated with placebo. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis.

Neuroleptic Malignant Syndrome (NMS) – A potentially fatal symptom complex sometimes referred to as Neuroleptic Malignant Syndrome (NMS) has been reported in association with administration of antipsychotic drugs, including ZYPREXA. Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis and cardiac dysrhythmia). Additional signs may include elevated creatinine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure.

The diagnostic evaluation of patients with this syndrome is complicated. In arriving at a diagnosis, it is important to exclude cases where the clinical presentation includes bot serious medical illness (e.g., pneumonia, systemic infection, etc.) and untreated or inadequately treated extrapyramidal signs and symptoms (EPS). Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever, and primary central nervous system pathology.

The management of NMS should include: 1) immediate discontinuation of antipsychotic drugs and other drugs not essential to concurrent therapy; 2) intensive symptomatic treatment and medical monitoring; and 3) treatment of any concomitant serious medical problems for which specific treatments are available. There is no general agreement about specific pharmacological treatment regimens for NMS.

If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences of NMS have been reported.

Tardive Dyskinesia – A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs. Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to rely upon prevalence estimates to predict, at the inception of antipsychotic treatment, which patients are likely to develop the syndrome. Whether antipsychotic drug products differ in their potential to cause Tardive dyskinesia is unknown.

The risk of developing Tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses.

There is no known treatment for established cases of Tardive dyskinesia, although the syndrome may remit, partially or completely, if antipsychotic treatment is withdrawn. Antipsychotic treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of syndrome and thereby may possibly mask the underlying process. The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown.

Given these considerations, ZYPREXA should be prescribed in a manner that is most likely to minimize the occurrence of Tardive dyskinesia. Chronic antipsychotic treatment should generally be reserved for patients (1) who suffer from a chronic illness that is known to respond to antipsychotic drugs, and (2) for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate. In patients who do require chronic treatment, the smallest dose and the shortest duration of treatment producing a satisfactory clinical response should be sought. The need for continued treatment should be reassessed periodically.

If signs and symptoms of Tardive dyskinesia appear in a patient on ZYPREXA, drug discontinuation should be considered. However, some patients may require treatment with ZYPREXA despite the presence of the syndrome.

For specific information about the warnings of lithium or valproate, refer to the WARNINGS section of the package inserts for these other products.

PRECAUTIONS

General

Hemodynamic Effects – ZYPREXA may induce orthostatic hypotension associated with dizziness, tachycardia, and in some patients, syncope, especially during the initial dose-titration period, probably reflecting its α1-adrenergic antagonistic properties. Hypotension, bradycardia with or without hypotension, tachycardia, and syncope were also reported during the clinical trials with intramuscular ZYPREXA for injection. In an open-label clinical pharmacology study in non-agitated patients with schizophrenia in which the safety and tolerability of intramuscular ZYPREXA were evaluated under a maximal dosing regimen (three 10 mg doses administered 4 hours apart), approximately one-third of these patients experienced a significant orthostatic decrease in systolic blood pressure (i.e., decrease ≥30 mmHg) (see DOSAGE AND ADMINISTRATION). Syncope was reported in 0.6% (15/2500) of ZYPREXA-treated patients in phase 2-3 oral ZYPREXA studies and in 0.3% (2/722) of ZYPREXA-treated patients with agitation in the intramuscular ZYPREXA for injection studies. Three normal volunteers in phase 1 studies with intramuscular ZYPREXA experienced hypotension, bradycardia, and sinus pauses of up to 6 seconds that spontaneously resolved (in 2 cases the events occurred on intramuscular olanzapine, and in 1 case, on oral ZYPREXA). The risk for this sequence of hypotension, bradycardia, and sinus pause may be greater in nonpsychiatric patients compared to psychiatric patients who are possibly more adapted to certain effects of psychotropic drugs.

For oral ZYPREZA therapy, the risk of orthostatic hypotension and syncope may be minimized by initiating therapy with 5 mg QD ( see DOSAGE AND ADMINISTRATION). A more gradual titration to the target dose should be considered if hypotension occurs.

For intramuscular ZYPREXA for injection therapy, patients should remain recumbent if drowsy or dizzy after injection until examination has indicated that they are not experiencing postural hypotension and/or bradycardia.

ZYPREXA should be used with particular caution in patients with known cardiovascular disease (history of myocardial infarction or ischemia, heart failure, or conduction abnormalities), cerebrovascular disease, and conditions which would predispose patients to hypotension dehydration, hypovolemia, and treatment with antihypertensive medications) where the occurrence of syncope, or hypotension and/or bradycardia might put the patient at increased medical risk.

Seizures – During premarketing testing, seizures occurred in 0.9% (22/2500) of ZYPREXA-treated patients. There were confounding factors that may have contributed to the occurrence of seizures in many of these cases. ZYPREXA should be used cautiously in patients with a history of seizures or with conditions that potentially lower the seizure threshold, e.g., Alzheimer’s dementia. Conditions that lower the seizure threshold may be more prevalent in a population of 65 years or older.

Hyperprolactinemia - As with other drugs that antagonize dopamine D² receptors, ZYPREXA elevates prolactin levels, and a modest elevation persist during chronic administration. Tissue culture experiments indicate that approximately one=-third of human breast cancers are prolactin dependent in vitro, a factor of potential importance if the prescription of these drugs is contemplated in a patient with previously detected breast cancer of this type. Although disturbances such as galactorrhea, amenorrhea, gynecomastia, and impotence have been reported with prolactin-evaluation compounds, the clinical significance of elevated serum prolactin levels is unknown for most patients, As is common with compounds which increase prolactin release, an increase in mammary gland neoplasia was observed in the ZYPREXA carcinogenicity studies conducted n mice and rats (see Carcinogenesis). However, neither clinical studies nor epidemiologic studies have shown an association between chronic administration of this class of drugs and tumorigenesis in humans; the available evidence is considered too limited to be conclusive.

Transaminase Elevations – In placebo-controlled studies, clinically significant ALT (SGPT) elevation (≥3 times the upper limit of the normal range) were observed in 2% (6/243) of patients exposed to ZYPREXA compared to none (0/115) of the placebo patients. None of these patients experienced jaundice. In two of these patients, liver enzymes decreased toward normal despite continued treatment and in two others, enzymes decreased upon discontinuation of ZYPREXA. In the remaining two patients, one, seropositive for hepatitis C, and persistent enzyme elevation for four months after discontinuation, and the other had insufficient follow-up to determine if enzymes normalized.
Within the larger premarketing database of about 2400 patients with baseline SGPT ≤90 IU/L, the incidence of SGPT elevation to >200 IU/L was 2% (50/2381). Again, none of these patients experienced jaundice or other symptoms attributable to live impairment and most had transient changes that tended to normalize while ZYPREXA treatment was continued.

Among 2500 patients in oral ZYPREXA clinical trials, about 1% (23/2500) discontinued treatment due to transaminase increases.

Caution should be exercised inpatients with signs and symptoms of hepatic impairment, in patients with pre-existing conditions associated with limited hepatic functional reserve, and in patients who are being treated with potentially hepatotoxic drugs. Periodic assessment of transaminases is recommended in patients with significant hepatic disease (see Laboratory Tests).

Potential for Cognitive and Motor Impairment – Somnolence was a commonly reported adverse event associated with ZYPREXA treatment, occurring at an incidence of 26% in ZYPREXA patients compared to 15% in placebo patients. This adverse event was also dose related. Somnolence led to discontinuation in 0.4% (9/2500) of patients in the premarketing database.

Since ZYPREXA has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that ZYPREXA therapy does not affect them adversely.

Body Temperature Regulation – Disruption of the body’s ability to reduce core body temperature has been attributed to antipsychotic agents. Appropriate care is advised when prescribing ZYPREXA for patients who will be experiencing conditions which may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medication with anticholinergic activity, or being subject to dehydration.

Dysphagia – Esophageal dysmotility and aspiration have been associated with antipsychotic drug use. Aspiration pneumonia is a common cause of morbidity and mortality in patients with advanced Alzheimer’s disease. ZYPREXA and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia.

Suicide – The possibility of a suicide attempt is inherent in schizophrenia and in bipolar disorder, and close supervision of high-risk patients should accompany drug therapy. Prescriptions for ZYPREXA should be written for the smallest quantity of tablets consistent with good patient management, in order to reduce the risk of overdose.
Use in Patients with Concomitant Illness – Clinical experience with ZYPREXA in patients with certain concomitant systemic illnesses (see Renal Impairment and Hepatic Impairment under CLINICAL PHARMACOLOGY, Special Populations) is limited.

ZYPREXA exhibits in vitro muscarinic receptor affinity. In premarketing clinical trials with ZYPREXA, ZYPREXA was associated with constipation, dry mouth, and tachycardia, all adverse events possibly related to cholinergic antagonism. Such adverse events were not often the basis for discontinuations from ZYPREXA, but ZYPREXA should be used with caution in patients with clinically significant prostatic hypertrophy, narrow angle glaucoma, or a history of paralytic ileus.
In five placebo-controlled studies of XYPREXA in elderly patients with dementia-related psychosis (n=1184), the following treatment-emergent adverse events were reported in ZYPREXA-treated patients at an incidence of at least 2% and significantly greater than placebo-treated patients: falls, somnolence, peripheral edema, abnormal gait, urinary incontinence, lethargy, increased weight, asthenia, pyrexia, pneumonia, dry mouth and visual hallucinations. The rate of discontinuation due to adverse events was significantly greater with ZYPREXA than placebo (13% vs. 7%). As with other CNS-active drugs, ZYPREXA should be used with caution in elderly patients with dementia. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis. If the prescriber elects to treat elderly patients with dementia-related psychosis, vigilance should be exercised (see WARNINGS).

ZYPREXA has not been evaluated or used to any appreciable extent in patients with a recent history of myocardial infarction or unstable heart disease. Patients with these diagnoses were excluded from premarketing clinical studies. Because of the risk of orthostatic hypotension with ZYPREXA, caution should be observed in cardiac patients (see Hemodynamic Effects).

For specific information about the precautions of lithium or valproate, refer to PRECAUTIONS section of the package inserts for these other products.

Information of Patients

Physicians are advised to discuss the following issues with patients for whom they prescribe ZYPREXA:

Orthostatic Hypotension – Patients should be advised of the risk of orthostatic hypotension, especially during the period of initial dose titration and in association with the use of concomitant drugs that may potentiate the orthostatic effect of ZYPREXA, e.g., diazepam or alcohol (see Drug Interactions).

Interference with Cognitive and Motor Performance – Because ZYPREXA has the potential to impair judgment, thinking, or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that ZYPREXA therapy does not affect them adversely.

Pregnancy – Patients should be advised to notify their physician if they become pregnant or intend to become pregnant during therapy with ZYPREXA.

Nursing – Patients should be advised not to breast-feed an infant if they are taking ZYPREXA.

Concomitant Medication – Patients should be advised to inform their physicians if they are taking, or plan to take, any prescription or over-the-counter drugs, since there is a potential for interactions.

Alcohol – Patients should be advised to avoid alcohol while taking ZYPREXA.
Heat Exposure and Dehydration – Patients should be advised regarding appropriate care in avoiding overheating and dehydration.
Phenylketonurics – ZYPREXA ZYDIS (Olanzapine orally disintegrating tablets) contains phenylalanine (0.34, 0.45,0.67, or 1.90 mg per 5, 10, 15, or 20 mg tablet, respectively).

Laboratory Tests

Periodic assessment of transaminases is recommended in patients with significant hepatic disease (see Transaminase Elevations).
Drug Interactions
The risks of using ZYPREXA in combination with other drugs have not been extensively evaluated in systematic studies. Given the primary CNS effects of ZYPREXA, caution should be used when ZYPREXA is taken in combination with other centrally acting drugs and alcohol.

Because of its potential for inducing hypotension, ZYPREXA, may enhance the effects of certain antihypertensive agents.
ZYPREXA may antagonize the effects of levadopa and dopamine agonists.

The Effect of Other Drugs on ZYPREXA – Agents that induce CYP1A2 or glucuronyl transferase enzymes, such as omeprazole and rifamipin, may cause an increase in ZYPREXA clearance. Inhibitors of CYP1A2 could potentially inhibit ZYPREXA clearance. Although ZYPREXA is metabolized by multiple enzyme systems, induction or inhibition of a single enzyme may appreciably alter ZYPREXCA clearance. Therefore, a dosage increase (for induction) or a dosage decrease (for inhibition) may need to be considered with specific drugs.

Charcoal – The admini9stration of activated charcoal (1g) reduced the Cmax and AUC of oral ZYPREXA by about 60%. A peak ZYPREXA levels are not typically obtained until about 6 hours after dosing, Charcoal may be a useful treatment for ZYPREXA overdose.
Cimetidine and Antacids – Single doses of cimetidine (800 mg) or aluminum- and magnesium-containing antacids did not affect the oral bioavailability of ZYPREXA.
Carbamazepine – Carbamazepine therapy (200 mg bid) causes an approximately 50% increase in the clearance of ZYPREXA. This increase is likely due to the fact that carbamazepine is a potent inducer of CYP1A2 activity. Higher daily doses of carbamazepine may cause an even greater increase in ZYPREXA clearance.
Ethanol – Ethanol (45 mg/70 kg single dose) did not have an effect on ZYPREXA pharmacokinetics.

Fluoxetine – Fluoxetine (60 mg single dose of 60 mg daily for 8 days) causes a small (mean 16%) increase in the maximum concentration of ZYPREXA and a small (mean 16%) decrease in ZYPREXA clearance. The magnitude of the impact of this factor is small in comparison to the overall variability between individuals, and therefore dose modification is not routinely recommended.

FZyprexaamine – FZyprexaamine, a CYP1A2 inhibitor, decreases the clearance of ZYPREXA. This results in a mean increase in ZYPREXA Cmax following fZyprexaamine of 54% in female nonsmokers and 77% in male smokers. The mean increase in ZYPREXAAUC is 52% and 108%, respectively. Lower doses of ZYPREXA should be considered in patients receiving concomitant treatment with fZyprexaamine.

Warfin – Warfin (20 mg single dose) did not affect ZYPREXA pharmacokinetics.
Effect of ZYPREXA on Other Drugs – In vitro studies utilizing human liver microsomes suggest that ZYPREXA has little potential to inhibit CYP1A2, CYP2C9, CYP2C19, CYP2D6, and CYP3A. Thus, ZYPREXA is unlikely to cause clinically important drug interactions mediated by these enzymes.
Lithium – Multiple doses of ZYPREXA (10 mg for 8 days) did not influence the kinetics of lithium. Therefore, concomitant ZYPREXA administration does not require dosage adjustment of lithium.
Valproate – Studies in vitro using human liver microsomes determined that ZYPREXA has little potential to inhibit the major metabolic pathway, glucuronidation, of valproate. Further valproate has little effect on the metabolism of ZYPREXA in vitro. In vivo administration of ZYPREXA (10 mg daily for 2 weeks) did not affect the steady state plasma concentrations of valproate. Therefore, concomitant ZYPREXA administration does not require dosage adjustment of valproate.
Single doses of ZYPREXA did not affect the pharmacokinetics of imipramine or its active metabolite desipramine, and warfarin. Multiple doses of ZYPREXA did not influence the kinetics of diazepam and its active metabolite N-desmethyldiazepam, ethanol, or biperiden. However, the co-administration of either diazepam or ethanol with ZYPREXA potentiated the orthostatic hypotension observed with ZYPREXA. Multiple doses of ZYPREXA did not affect the pharmacokinetics of theophylline or its metabolites.
Lorazepam – Administration of intramuscular lorazepam (2 mg) 1 hour after intramuscular ZYPREXA for injection (5 mg) did not significantly affect the pharmacokinetics of ZEPRXA, unconjugated lorazepam, or total lorazepam. However, this co-administration of intramuscular lorazepam and intramuscular ZYPREXA for infection added to the somnolence observed with either drug alone.

Carcinogenesis, Mutagenesis, Impairment of Fertility

Carcinogenesis – Oral carcinogenicity studies were conducted in mice and rats. ZYPREXA was administered to mice in tow 78-week studies at doses of 3, 10, 30/20 mg/kg/day (equivalent to 0.8-5 times the maximum recommended human daily oral dose on a mg/m² basis) and 0.25, 2, 8 mg/kg/day (equivalent to 0.06-2 times the maximum recommended human daily oral dose on a (mg/m² basis). Rats were dosed for 2 years at doses of 0.25, 1, 2.5, 4 mg/kg/day (males) and 0.25, 1, 4, 8 mg/kg/day (females)(equivalent to 0.13-2 and 0.13-4 times the maximum recommended human daily oral dose on a mg/m² basis, respectively). The incidence of liver hemangiomas and hemangiosarcomas was significantly increased in one mouse study in female mice dosed at 8mg/kg/day (2 times the maximum recommended human daily oral dose on a mg/m² basis).
These tumors were not increased in another mouse study in females dosed at 10 or 30/20 mg/kg/day (2-5 times the maximum recommended human daily oral dose on a mg/m² basis); in this study, there was a high incidence of early mortalities in males of the 30/20 mg/kg/day group. The incidence of mammary gland adenomas and adenocarcinomas was significantly increased in female mice dosed at ≥2 mg/kg/day and in female rats dosed at ≥4 mg/kg/day (0.5 and 2 times the maximum recommended human daily oral dose on a mg/m² basis, respectively). Antipsychotic drugs have been shown to chronically elebate prolactin levels in rodents. Serum prolactin levels were not measured during the ZYPREXA cacinogenicty studies; however, measurements during subchronic toxicity studies showed that ZYPREXA elevated serum prolactin levels up to 4-fold in rats at the same doses used in the carcinogenicity study. An increase in mammary gland neoplasms has been found in rodents after chronic administration of other antipsychotic drugs and is considered to be prolactin mediated. The relevance for human risk of the finding of prolactin mediated endocrine tumors in rodents is unknown (see Hyperprelactinemia under PRECAUTIONS, General).

Mutagenesis – No evidence of mutagenic potential for ZYPREXA was found in the Ames reverse mutation test, in vivo micronucleus test in mice, the chromosomal aberration test in Chinese hamster ovary cells, unscheduled DNA synthesis test in rat hepatocytes, induction of forward mutation test in mouse lymphoma cells, or in vivo sister chromatid exchange test in bone marrow if Chinese hamsters.

Impairment of Fertility – In an oral fertility and reproductive performance study in rats, male mating performance, but not fertility, was impaired at a dose of 22.34 mg/kg/day and female fertility was decreased at a dose of 3 mg/kg/day (11 and 1.5 times the maximum recommended human daily oral dose on a mg/m² basis, respectively). Discontinuance of ZYPREXA treatment reversed the effects on male mating performance. In female rats, the precoital period was increased and the mating index reduced at 5 mg/kg/day (2.5 times the maximum recommended human daily oral dose on a mg/m² basis). Diestrous was prolonged and estrous delayed at 1.1 mg/kg/day (0.6 times the maximum recommended human daily oral dose on a mg/m² basis); therefore, ZYPREXA may produce a delay in ovulation.

Pregnancy

Pregnancy Category C – In oral reproduction studies in rats at doses up to 18 mg/kg/day and in rabbits at doses up to 30 mg/kg/day (9 and 30 times the maximum recommended human daily oral dose on a mg/m² basis, respectively) no evidence of teratogenicity was observed. In an oral rat teratology study, early resorptions and increased numbers of nonviable fetuses were observed at a dose of 18 mg/kg/day (9 times the maximum recommended human daily oral dose on a mg/m² basis). Gestation was prolonged at 10 mg/kg/day (5 times the maximum recommended human daily oral dose on a mg/m² basis). In an oral rabbit teratology study, fetal toxicity (manifested as increased resorptions and decreased fetal weight) occurred at a maternally toxic dose of 30 mg/kg/day (30 times the maximum recommended human daily oral dose on a mg/m² basis).

Placental transfer of ZYPREXA occurs in rat pups.

There are no adequate and well-controlled trials with ZYPREXA in pregnant females. Seven pregnancies were observed during clinical trials with ZYPREXA, including 2 resulting in normal births, 1 resulting in neonatal death due to a cardiovascular defect, 3 therapeutic abortions, and 1 spontaneous abortion. Because animal reproduction studies are not always predictive of human response, this drug should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Labor and Delivery

Parturition in rats was not affected by ZYPREXA. The effect of ZYPREXA on labor and delivery in humans is unknown.
Nursing Mothers
ZYPREXA was excreted in milk of treated rats during lactation. It is not known if ZYPREXA is excreted in human milk. It is recommended that women receiving ZYPREXA should not breast-feed.

Pediatric Use

Safety and effectiveness in pediatric patients have not been established.
Geriatric Use

Of the 2500 patients in premarketing clinical studies with oral ZYPREXA, 11% (263) were 65 years of age or over. In patients with schizophrenia, there was no indication of any different tolerability of ZYPREXA in the elderly compared to younger patients. Studies in elderly patients with dementia-related psychosis have suggested that there may be a different tolerability profile in this population compared to younger patients with schizophrenia. As with other CNS-active drugs, ZYPREXA should be used with caution in elderly patients with dementia. ZYPREXA is not approved for the treatment of patients with dementia-related psychosis. If the prescriber elects to treat elderly patients with dementia-related psychosis, vigilance should be exercised. Also, the presence of factors that might decrease paharmacokinetic clearance or increase the pharmacodynamic response to ZYPREXA should lead to consideration of a lower starting dose for any geriatric patient (see WARNINGS, PRECAUTIONS, AND DOSAGE AND ADMINISTRATION).
ADVERSE REACTIONS

The information below is derived from a clinical trial database for ZYPREXA consisting of 8661 patients with approximately 4165 patient-years of exposure to oral ZYPREXA and 722 patients with exposure to intramuscular ZYPREXA for injection. This database includes: (1) 2500 patients who participated in multiple-dose oral ZYPREXA premarketing trials in schizophrenia and Alzheimer’s disease representing approximately 1122 patient-years of exposure as of February 14, 1995; (2) 182 patients who participated in oral ZYPREXA premarketing bipolar mania trials representing approximately 66 patient-years of exposure; (3) 191 patients who participated in an oral ZYPREXA trial of patients having various psychiatric symptoms in association with Alzheimer’s disease representing approximately 29 patient-years of exposures; (4) 5788 patients form 88 additional oral ZYPREXA clinical trials as of December 31, 2001; and (5) 722 patients who participated in intramuscular ZYPREXA for injection premarketing trials in agitated patients with schizophrenia, Bipolar I Disorder (manic or mixed episodes), or dementia. In addition, information from the premarketing 6-week clinical study database for ZYPREXA in combination with lithium or valproate, consisting of 224 patients who participated in bipolar mania trials with approximately 22 patient-years of exposure, is included below.
The conditions and duration of treatment with ZYPREXA varied greatly and included (in overlapping categories) open-label and double-blind phases of studies, inpatients and outpatients, fixed-dose and dose-titration studies, and short-term or longer-term exposure. Adverse reactions were assessed by collecting adverse events, results of physical examinations, vital signs, weights, laboratory analytes, ECGs. Chest x-rays, and results of ophthalmologic examinations.

Certain portions of the discussion below relating to objective or numeric safety parameters, namely, dose-dependent adverse events, vital sign changes, weight gain, laboratory changes, and ECG changes are derived from studies in patients with schizophrenia and have not been duplicated for bipolar mania or agitation. However, this information is also generally applicable to bipolar mania and agitation.

Adverse events during exposure were obtained by spontaneous report and recorded by clinical investigators using terminaology of their won choosing. Consequently, it is not possible to provide a meaningful estimate of the proportion of individuals experiencing adverse event without first grouping similar types of events into a smaller number of standardized event categories. In the tables and tabulations that follow, standard COSTART dictionary terminology has been used initially to classify reported adverse events.
The stated frequencies of adverse events represent the proportion of individuals who experienced, at least once, a treatment-emergent adverse event of the type listed. An event was considered treatment emergent if it occurred for the first time or worsened while receiving therapy following baseline evaluation. The reported events do not include those event terms that were so general as to be uninformative. Events listed elsewhere in labeling may not be repeated below. It is important to emphasize that, although the events occurred during treatment with ZYPREXA, they were not necessarily caused by it. The entire label should be read to gain a complete understanding of the safety profile of ZYPREXA.

The prescriber should be aware that the figures in the tables and tabulations cannot be used to predict the incidence of side effects in the course of usual medical practice where patient characteristics and other factors differ from those that prevailed in the clinical trials. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigations involving different treatments, uses, and investigators, The cited figures, however, do provide the prescribing physician with some basis for estimating the relative contribution of drug and nondrug factors to the adverse event incidence in the population studied.
Incidence of Adverse Events in Short-Term, Placebo-Controlled and Combination Trials

The following findings are based on premarketing trials of (1) oral ZYPREXA for schizophrenia, bipolar mania, a subsequent trial of patients having various psychiatric symptoms in association with Alzheimer’s disease, and premarketing combination trials, and (2) intramuscular ZYPREXA for injection in agitated patients with schizophrenia or bipolar mania.

Adverse Events Associated with Discontinuation of Treatment in Short-Term, Placebo-Controlled Trials
Schizophrenia – Overall, there was no difference in the incidence of discontinuation due to adverse events (5% for oral ZYPREXA vs. 6% for placebo). However, discontinuations due to increased in SGPT were considered to be drug related (2% for oral ZYPREXA vs. 0% for placebo) (see PRECAUTIONS).

Bipolar Mania Monotherapy – Overall, there was no difference in the incidence of discontinuation due to adverse events (2% for oral ZYPREXA vs. 2% for placebo).

Agitation – Overall, there was no difference in the incidence of discontinuation due to adverse events (0.4% for intramuscular ZYPREXA for injection vs. 0% for placebo).
Adverse Events Associated with Discontinuation of Treatment in Short-Term Combination Trials

Bipolar Mania Combination Therapy – In a study of patients who were already tolerating either lithium or valproate as monotherapy, discontinuation rates due to adverse events were 11% for the combination of oral ZYPREXA with lituium or valproate compared to 2% for patients who remained on lithium or valproate monotherapy. Discontinuations with the combination of oral ZYPREXA and lithium or valproate that occurred in more than 1 patient were: somnolence (3%), weight gain (1%), and peripheral edema (1%).

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Am J Emerg Med. 2009 Jun;27(5):607-616.

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Soc Sci Med. 2009 May 27. [Epub ahead of print]

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