Olanzapine is an antipsychotic used in the treatment of schizophrenia and bipolar disorder. It also has been evaluated as an adjunctive medication for the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV) in patients with cancer.
Chiu, L., Chow, R., Popovic, M., Navari, R.M., Shumway, N.M., Chiu, N., . . . DeAngelis, C. (2016). Efficacy of olanzapine for the prophylaxis and rescue of chemotherapy-induced nausea and vomiting (CINV): A systematic review and meta-analysis. Supportive Care in Cancer, 24, 2381–2392.
STUDY PURPOSE: To evaluate the effectiveness of olanzapine compared to other antiemetic regimens for preventative and breakthrough chemotherapy-induced nausea and vomiting (CINV). A secondary objective is to evaluate the effectiveness of 5 mg compared to 10 mg olanzapine for the prevention of CINV.
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Active antitumor treatment
APPLICATIONS: Elder care
Efficacy of Acute Phase: Olanzapine was statistically superior to non-olanzapine regimens for emesis (RR = 1.10, 95% CI [1.03, 1.17]) but not nausea. The 10 mg olanzapine was statistically superior to a non-olanzapine regimen for emesis and nausea.
Efficacy of Delayed Phase: Olanzapine was statistically superior to standard antiemetic regimens for emesis (RR = 1.31, 95% CI [1.14, 1.52]) and for nausea (RR = 1.50, 95% CI [1.15, 1.97]). The 10 mg olanzapine was statistically superior to a non-olanzapine regimen for emesis (RR = 1.31, 95% CI [1.11, 1.54]) and nausea (RR = 1.50, 95% CI [1.15, 1.97]).
Efficacy Overall: Olanzapine was statistically superior to standard anti-emetic regimens for emesis (RR = 1.41, 95% CI [1.18, 1.68]) and for nausea (RR 1.53, 95% CI [1.18, 1.97]). Olanzapine 5 mg and 10 mg were both statistically superior for emesis, and 10 mg strength was superior for nausea. No studies were available for nausea with 5 mg.
Efficacy of Breakthrough: Only emesis (not nausea) was available for analysis, and olanzapine showed superiority (RR = 2.09, 95% CI [1.63, 2.68]) to non-olanzapine regimens.
Olanzapine is effective in treating emesis at all time points and is effective in treating nausea in the delayed phase. More studies are needed to determine the most effective dosing.
Olanzapine should be used as an adjunct medication for the treatment of acute chemotherapy related vomiting, breakthrough vomiting, and delayed CINV.
Chow, R., Chiu, L., Navari, R., Passik, S., Chiu, N., Popovic, M., . . . DeAngelis, C. (2015). Efficacy and safety of olanzapine for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV) as reported in phase I and II studies: A systematic review. Supportive Care in Cancer, 24, 1001–1008.
STUDY PURPOSE: To summarize evidence from phase I and II trials in which olanzapine was used for the prophylaxis of chemotherapy-induced nausea and vomiting (CINV)
PHASE OF CARE: Active antitumor treatment
The rate of complete control (no emesis, no rescue medication, and no significant nausea) was only identified in one study. Complete response rates were reported in three studies, and they ranged from 75%–100% in the acute phase and 72%–92.5% in the overall phase. In four trials, olanzapine was used as an adjunct with other antiemetics. One study was a retrospective chart review.
The findings of this study suggest that olanzapine can be beneficial in preventing CINV.
The potential role of olanzapine in the prevention and management of CINV is unclear. This review provides limited evidence of the effects of olanzapine for CINV. Future studies need to compare olanzapine as an adjuvant to recommended antiemetics or olanzapine as a single agent compared to regimens with clear efficacy for the prevention of CINV.
Wang, X.F., Feng, Y., Chen, Y., Gao, B.L., & Han, B.H. (2014). A meta-analysis of olanzapine for the prevention of chemotherapy-induced nausea and vomiting. Scientific Reports, 4, 4813.
PHASE OF CARE: Active antitumor treatment
APPLICATIONS: Elder care, palliative care
Five out of six studies demonstrated an increase in complete response in patients receiving standard antiemetic regimens plus olanzapine on day 1 of chemotherapy (odds ratio [OR] = 1.95, 95%; confidence interval [CI] = 1.17–3.23; p = 0.01). Five out of six studies showed a cumulative delay in vomiting (OR = 2.65, 95%; CI = 1.36–5.15; p = 0.004). Overall complete response relative risk was improved (4.07, 95%; CI = 1.59–10.43). Also note the following: delayed-phase antinausea effects in olanzapine-containing antiemetic regimens (OR = 2.79, 95%; CI = 1.76–4.43; p = 0.0001); antinausea effects in the overall phase (OR = 3.40, 95% CI = 2.32–5.00; p = 0.00001); and no superiority in the acute phase (RR = 1.34, 95%; CI = 0.77–2.34; p = 0.30).
Complete response is more likely in patients who received antiemetic regimens containing olanzapine compared to patients who did not receive olanzapine. Olanzapine is more effective in delayed CINV than acute.
Olanzapine may add CINV control when added to a standard antiemetic regimen during the delayed phase.
Yoodee, J., Permsuwan, U., & Nimworapan, M. (2017). Efficacy and safety of olanzapine for the prevention of chemotherapy-induced nausea and vomiting: A systematic review and meta-analysis. Critical Reviews in Oncology/Hematology, 112, 113–125.
STUDY PURPOSE: The primary aim of this systematic review was to compare the efficacy and safety of olanzapine with standard antiemetics.
TYPE OF STUDY: Systematic review/meta-analysis
DATABASES USED: MEDLINE, EMBASE, SCOPUS, Cochran Central Register of Controlled Trials
YEARS INCLUDED: Inception to July 15, 2016
INCLUSION CRITERIA: The studies of interest were those that reported either olanzapine as add-on treatment (dexamethasone plus 5-HT3 antagonist, with or without NK1 antagonist) or olanzapine monotherapy compared to standard treatment.
EXCLUSION CRITERIA: Duplicate data and non-English language studies.
TOTAL REFERENCES RETRIEVED: 573
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two independent reviewers
FINAL NUMBER STUDIES INCLUDED: 16 studies however, only 9 were pooled for statistical analysis because 1 was an observational study, and 6 clinical trials did not have a comparison group.
TOTAL PATIENTS INCLUDED IN REVIEW 1,308 (in the 9 studies included in analysis)
SAMPLE RANGE ACROSS STUDIES: 17-380
KEY SAMPLE CHARACTERISTICS: Multiple tumor types, focused on patients receiving olanzapine.
PHASE OF CARE: Active anti-tumor treatment
The results of the combined studies included in the meta-analysis showed that CR (defined as no emesis and no rescue drugs) was achieved more frequently for delayed CINV (RR = 1.77, 95% CI [1.07, 1.49]) and overall CINV (RR = 1.32; 95% CI [1.08, 1.62]). Olanzapine was not superior to traditional antiemetic therapy for acute CINV. The most frequently occurring adverse events were drowsiness and constipation.
Nurses caring for patients with delayed CINV can consider the use of olanzapine, but also must recognize the common occurring drowsiness and constipation with the use of the medication.
Abe, M., Hirashima, Y., Kasamatsu, Y., Kado, N., Komeda, S., Kuji, S., . . . Ito, K. (2015). Efficacy and safety of olanzapine combined with aprepitant, palonosetron, and dexamethasone for preventing nausea and vomiting induced by cisplatin-based chemotherapy in gynecological cancer: KCOG-G1301 phase II trial. Supportive Care in Cancer, 24, 675–682.
To investigate the effects of olanzapine as an adjunct to triplet antiemetic therapy for the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients receiving highly emetogenic chemotherapy
All patients in the trial were receiving triplet therapy in accordance with Japanese guidelines and 5 mg olanzapine one day prior to cisplatin administration then once daily on days 1–5 at bedtime. Metoclopramide was used as rescue therapy for breakthrough emesis. Patients were hospitalized during treatment.
Prospective trial
There were no grade 3 or 4 adverse events. In the overall phase (acute and delayed phases), the complete response rate was 92.5% with 97.5% in the acute phase and 95% in the delayed phase. The rate for no nausea was 87.5% in the acute phase and 67.5% in the delayed phase. The authors provided a comparison of this study's results with those of a collaborative group trial using triplet therapy. This comparison showed that the addition of olanzapine was associated with better response rates across all phases and higher rates of nausea control. The adverse effects reported were low-grade and included constipation, dry mouth, and dizziness.
The addition of olanzapine to triplet antiemetic therapy in patients receiving highly emetogenic chemotherapy was associated with high rates of complete CINV control across all phases and relatively low rates of nausea during the acute phase.
Triplet drug therapy to prevent CINV is recommended and is effective with highly emetogenic chemotherapy. However, even with this approach, the control and prevention of nausea is challenging. The findings of this study suggest the addition of olanzapine to triplet therapy may improve nausea control and overall CINV prevention with no severe adverse effects. This study has several limitations, but provides promising results. Additional, well-designed research testing the impact of olanzapine for CINV prevention is warranted.
Babu, G., Saldanha, S.C., Kuntegowdanahalli Chinnagiriyappa, L., Jacob, L.A., Mallekavu, S.B., Dasappa, L., . . . Arroju, V. (2016). The efficacy, safety, and cost benefit of olanzapine versus aprepitant in highly emetogenic chemotherapy: A pilot study from South India. Chemotherapy Research and Practice, 2016, 3439707.
To compare the efficacy, safety, and cost of olanzapine-based triplet antiemetics compared to the use of aprepitant as part of antiemetics in chemotherapy-naïve patients receiving highly emetogenic chemotherapy
The olanzapine group received 10 mg olanzapine orally (PO), 0.25 mg palonosetron intravenously (IV), and 20 mg dexamethasone IV on day 1; and then 5 mg olanzapine PO and 4 mg dexamethasone PO on days 2–4. The aprepitant group was given 125 mg aprepitant PO, 0.25 mg palonosetron IV, and 12 mg dexamethasone IV on day 1; 80 mg aprepitant PO on days 2 and 3; and 4 mg dexamethasone PO on days 2–4. Patients were asked to record the intensity of nausea, the use of rescue medication, and vomiting daily in a diary. Patients were contacted daily for reminders to record symptoms.
PHASE OF CARE: Active antitumor treatment
No significant differences existed between groups in complete response rates or nausea severity. No grade 3 or 4 toxicities existed. Adverse events associated with olanzapine were sedation and dizziness in less than 10% of patients.
Olanzapine-based triplet antiemetic therapy was as effective as aprepitant-based triplet antiemetics in this study.
Findings suggest that the use of olanzapine in substitution for an NK1 in a triplet antiemetic regimen was effective. The study is limited by its lack of random assignment to study groups, but the groups were well matched on most demographic and other treatment variables. Olanzapine is much less expensive than an NK1 and may be a good alternative for patients who have limited financial resources or insurance coverage for antiemetics.
Chiu, L., Chiu, N., Chow, R., Zhang, L., Pasetka, M., Stinson, J., . . . DeAngelis, C. (2016). Olanzapine for the prophylaxis and rescue of chemotherapy induced nausea and vomiting (CINV): A retrospective study. Annals of Palliative Medicine, 5, 172–178.
Evaluate the safety and efficacy of olanzapine for prevention and rescue of CINV
Medical records of adult patients who received one or more doses of olanzapine for prophylaxis of CINV or treatment of breakthrough CINV were reviewed. Routinely patients are phoned by a pharmacist or research assistant 72 hours after each chemotherapy cycle and an assessment of CINV is documented in the electronic record. Patients were on various chemotherapy and antiemetic regimens.
Retrospective descriptive
Olanzapine was used for breakthrough in 154 patients over 193 treatment cycles. 88.1% of patients reported that it improved nausea, and 21.8% reported it improved vomiting. Twenty patients had been given olanzapine for prophylaxis. Among these 100% reported it improved nausea, and 35% said it improved vomiting. Analysis showed that olanzapine effects were not related to cycle, emetogenicity of the chemotherapy, or antiemetic regimen used. Side effects observed were sedation with continuation of olanzapine (29.5%).
Olanzapine was shown to have been effective as a rescue medication for CINV and may be effective for CINV prophylaxis.
Olanzapine can be effective as a rescue medication for CINV and as part of a CINV prophylaxis regimen.
Liu, J., Tan, L., Zhang, H., Li, H., Liu, X., Yan, Z., . . . Zhang, D. (2015). QoL evaluation of olanzapine for chemotherapy-induced nausea and vomiting comparing with 5-HT3 receptor antagonist. European Journal of Cancer Care, 24, 436–443.
To evaluate the effect of olanzapine on quality of life (QOL) during chemotherapy compared with a 5HT3 receptor antagonist
Patients receiving multiple different chemotherapy regimens were randomized to one of two groups. Group one received olanzapine 10 mg PO, azasetron 10mg IV, and dexamethasone 10 mg IV, followed by olanzapine 10 mg PO on days 2-5. The control group received azasetron 10 mg IV and dexamethasone 10 mg IV, followed by dexamethasone 10 mg IV on days 2-5. Use of breakthrough antiemetics was permitted based on clinical circumstances. It is not reported whether patients received one cycle only. Patients were not all chemotherapy naive, but this was not controlled in the sample description.
There was no significant difference in acute CINV, but delayed CINV showed complete response rates of 76.85% in the olanzapine group and 46.2% in the 5HT3 group (p < 0.05). CINV was also better controlled in five days post chemotherapy, with 85.95% in the olanzapine arm and 67.59% in the control arm. Not all patients completed QOL. Global health status, emotional functioning, social functioning, fatigue, CINV, and insomnia were improved in the olanzapine group. Pain and dyspnea improved in both groups.
CINV influences QOL for patients undergoing chemotherapy. Although olanzapine did not change CINV in the acute phase, it showed significance in the delayed CINV group. This demonstrated improvements in global health status, fatigue, and insomnia. 5HT3 antagonists were effective against acute CINV but not effective in delayed CINV.
Olanazapine offers another option for treatment of CINV. Other symptoms may also be controlled with this medication, such as insomnia, appetite loss, fatigue, and global health status. Nurses can consider this when standard medications are ineffective.
Mizukami, N., Yamauchi, M., Koike, K., Watanabe, A., Ichihara, K., Masumori, N., & Yamakage, M. (2014). Olanzapine for the prevention of chemotherapy-induced nausea and vomiting in patients receiving highly or moderately emetogenic chemotherapy: A randomized, double-blind, placebo-controlled study. Journal of Pain and Symptom Management, 47(3), 542–550.
To determine whether adding olanzapine to current standard antiemetic therapy could reduce the frequency of chemotherapy-induced nausea and vomiting (CINV) and improve patients’ quality of life (QOL) during chemotherapy
Randomized, double-blind, placebo-controlled trial
The olanzapine group achieved better total control (59% overall, 86% in the acute phase, and 64% in the delayed phase) than the control group (23% overall, 55% in the acute phase, and 23% in the delayed phase). The olanzapine group also achieved better complete protection and complete response except for acute phase complete response (p < .05). Furthermore, the olanzapine group experienced better QOL (p < .01), and the olanzapine group indicated that CINV did not affect their daily activities whereas 36% of the control group reported influence of CINV on daily life activities. There were significant differences between the VAS for nausea and satisfaction scores for additional medication. Most of the olanzapine group patients (91%) wished to receive same protocol for future chemotherapy. Dietary intake was better maintained by the olanzapine group with a significant difference on day 2 and days 4–6.
The addition of 5 mg/day of oral olanzapine to standard therapy can reduce the frequency of CINV and improve QOL for patients receiving highly or moderately emetogenic chemotherapy.
The addition of olanzapine to standard antiemetics, such as 5-HT3RA, steroids, and NK1RA, could achieve better control of CINV, especially for the delayed phase, with additional benefit in terms of QOL and less change in dietary intake. However, caution needs to be exercised in interpreting the result as the study allowed NK1 for the MEC, had age difference between the olanzapine and control group, and did not take risk factors of CINV into consideration, and the palonosetron dose of 0.75mg was higher than antiemetic recommendations.
Mukhopadhyay, S., Kwatra, G., Pamela, A.K., & Badyal, D. (2017). Role of olanzapine in chemotherapy-induced nausea and vomiting on platinum-based chemotherapy patients: A randomized controlled study. Supportive Care in Cancer, 25, 145–154.
To evaluate the efficacy of olanzapine in the prevention of chemotherapy-induced nausea and vomiting (CINV) in patients receiving platinum-based chemotherapy and prophylactic palonosetron and dexamethasone
This was a randomized, controlled, assessor-blind study.
Patients recorded the frequency and time of emetic episodes and the frequency and time of rescue antiemetics for the first five days. Patients also used the Multinational Association for Supportive Care in Cancer (MASCC) Antiemesis Tool (MAT) to record the control of nausea and vomiting and intensity of symptoms from days 1–5. Patients also recorded any adverse effects on days 1, 3, and 8–10 and as needed, as well as the duration and severity of the adverse effect. A trained nurse assessed all patients between day 8–10. At this time, the patients' overall quality of life was assessed using the European Organization for Research and Treatment of Cancer Core Quality of Life (EORTC QLQ-C30), version 3, questionnaire.
For patients receiving platinum-based chemotherapy, olanzapine is an effective addition for the prevention of CINV. The only side effect listed is more sedation.
Findings not generalizable
Olanazpine is effective for the prevention of CINV in this sample with few adverse effects. It may not be generalizable, but more studies are supporting its use.
Nakagaki, M., Barras, M., Curley, C., Butler, J.P., & Kennedy, G.A. (2017). A randomized trial of olanzapine versus palonosetron versus infused ondansetron for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients undergoing hematopoietic stem cell transplantation. Supportive Care in Cancer, 25, 607–613.
To compare the effectiveness of infused ondansetron, olanzapine, and palonosetron for the treatment of breakthrough chemotherapy-induced nausea and vomiting (CINV) in recipients of hematopoietic stem cell transplantation (HSCT)
Randomized, open-label, prospective study
Olanzapine is an effective treatment for breakthrough CINV after an allogeneic or autologous hematopoietic stem cell transplantation when used with standard prophylaxis of ondansetron and aprepitant.
For the treatment of breakthrough CINV in recipients of HSCT receiving prophylactic ondansetron and aprepitant, olanzapine is superior to palonosteron and ondansetron. This is an indication to include this as a part of patients' antiemetic regimens.
Navari, R.M., Nagy, C.K., Le-Rademacher, J., & Loprinzi, C.L. (2016). Olanzapine versus fosaprepitant for the prevention of concurrent chemotherapy radiotherapy-induced nausea and vomiting. The Journal of Community and Supportive Oncology, 14, 141–147.
To compare the effectiveness of an olanzapine-based triple-drug antiemetic regimen with a fosaprepitant-based triple-drug regimen
Patients were randomized to either olanzapine, palonosetron, and dexamethasone (OPD) or fosaprepitant, palonosetron, and dexamethasone (FPD) before the first course of chemotherapy. The OPD regimen was palonosetron 0.25 mg and dexamethasone 20 mg IV prior to chemotherapy and 10 mg PO olanzapine on days 1–4. The FPD regimen was 12 mg dexamethasone, 0.25 mg palonosetron and 150 mg fosaprepitant IV prior to chemotherapy, followed by oral dexamethasone 4 mg twice daily on days 2–3. Patients were allowed to take rescue medication. All patients received a placebo to ensure that the medication provided looked identical to the patient. Daily episodes of vomiting, symptom intensity, and use of rescue therapy were recorded by the patient in a diary for five days.
PHASE OF CARE: Active antitumor treatment
No difference existed between groups in complete response for the acute period. For the delayed and overall periods, those on the olanzapine regimen showed a CR rate of 76% compared to 74% in the comparison group. Twelve percent of the OPD group required rescue during the acute phase, and 12% required rescue medication during the delayed period. In the FPD group, 10% required rescue during the delayed phase, and 26% required rescue medication in the acute period. The percentage of patients with no nausea was higher in the OPD group in all phases (p < 0.01). Patients on olanzapine had more drowsiness that was resolved by day 3–4.
Findings suggest that both the standard triple-drug antiemetic regimen and the olanzapine-based regimen were effective in controlling vomiting. As a greater proportion of those receiving olanzapine had no nausea, the olanzapine regimen may provide greater nausea control.
This study showed that both antiemetic regimens were similar in terms of control of emesis and need for rescue medications, and that nausea was better controlled with olanzapine. Nausea has been more difficult to control with currently used antiemetic regimens. These results suggest that olanzapine-based regimens may provide better nausea control. Olanzapine is also generally much less expensive than NK1s, providing a good treatment alternative at a lower cost.
Navari, R.M., Qin, R., Ruddy, K.J., Liu, H., Powell, S.F., Bajaj, M., . . . Loprinzi, C.L. (2016). Olanzapine for the prevention of chemotherapy-induced nausea and vomiting. New England Journal of Medicine, 375, 134–142.
To evaluate olanzapine for chemotherapy-induced nausea and vomiting (CINV) prophylaxis in patients receiving highly emetogenic chemotherapy (HEC) and to evaluate potential toxic effects
Patients were stratified according to gender, chemotherapy regimen, and the specific 5HT3 used. All patients were on triplet antiemetic regimens. In addition, patients received 10 mg oral olanzapine daily or placebo on days 1–4. Patients were to complete daily records of vomiting, nausea severity, and use of rescue therapy.
PHASE OF CARE: Active antitumor treatment
During the acute phase, 73.8% on olanzapine had no nausea compared to 45.3% on placebo (p < 0.001), and in the delayed phase, 42.4% on olanzapine and 25.4% on placebo had no nausea (p = 0.001). The complete response rate with olanzapine in the acute phase was 85.7% compared to 64.6% with placebo (p < 0.001). In the delayed phase, complete response was 66.9% with olanzapine and 53.4% with placebo (p = 0.007). Those on olanzapine had significantly more sedation on day 2, which then resolved in the following days.
The addition of olanzapine as an adjunct to standard triplet antiemetic regimens for patients receiving HEC was more effective than placebo for CINV control.
Findings suggest that the use of olanzapine as an adjunct to usual triplet therapy for CINV control was effective in improving complete response rates and nausea, although complete response rates reported here are not higher than those often reported with standard triplet therapy. Nausea was also improved with olanzapine, although almost half the participants still had nausea in the delayed phase. Clinicians can consider the addition of olanzapine to standard antiemetic regimens for individuals at high risk for CINV or those who may have had inadequate CINV control in previous chemotherapy cycles. Ongoing research is still needed to achieve greater nausea control.
Sato, J., Kashiwaba, M., Komatsu, H., Ishida, K., Nihei, S., & Kudo, K. (2016). Effect of olanzapine for breast cancer patients resistant to triplet antiemetic therapy with nausea due to anthracycline-containing adjuvant chemotherapy. Japanese Journal of Clinical Oncology, 46, 415–420.
To determine the effectiveness and safety of adding olanzapine to triple antiemetic therapy with aprepitant, palonosetron, and dexamethasone as highly emetic anthracycline-containing adjuvant chemotherapy for patients with primary breast cancer
Forty-five patients with breast cancer who experienced greater than grade 1 nausea or any vomiting after the first cycle of chemotherapy using both epirubicin and cyclophosphamide were included. Low-dose olanzapine (2.5 mg per day) was administered orally from the first day of chemotherapy for four days, and the number of episodes of vomiting, scale of nausea, dietary intake, and somnolence were compared with the symptoms after the first cycle.
The nausea was significantly improved by adding olanzapine (p < 0.05). The mean nausea scale and dietary intake were improved by adding olanzapine.
Adding low-dose olanzapine for patients with insufficient nausea relief with triplet antiemetic therapy consisting of palonosetron, a steroid, and aprepitant can be effective and is tolerable.
Patients with breast cancer with highly emetogenic regimens containing both cyclophosphamide and anthracycline treated with triple therapy for resistant nausea could benefit from the addition of low-dose olanzapine.
Sorooshian, H., & Vo, L. (2015). A modified olanzapine regimen for the prevention of chemotherapy-induced nausea and vomiting. The Journal of Community and Supportive Oncology, 13, 388–391.
To compare regimens using fosaprepitant and olanzapine for chemotherapy-induced nausea and vomiting (CINV) prevention
Patients on regimens for the prevention of CINV who were receiving highly emetogenic chemotherapy (HEC) received either a medication regimen of fosaprepitant, ondansetron, and dexamethasone, or a regimen of olanzapine, ondansetron, and dexamethasone. Those on the olanzapine regimen only received dexamethasone on day 1. Both groups had additional rescue medication as needed. All patients were assessed within 24–72 hours for CINV via follow-up phone calls, with results documented in the electronic medical record.
Complete response defined as no emesis after cycle 1. A difference of 15% complete response (CR) rate was used as the limit for noninferiority testing.
The difference in the CR rate between groups was 8.9% in the acute phase, 12.9% in the delayed phase, and 8.6% overall. Statistical analysis showed that results in the olanzapine group were not inferior based on the difference level specified. Comparison of wholesale acquisition costs showed that the olanzapine regimen was less than 4% of the cost of the regimen using fosaprepitant ($8.58 versus $265.59).
The olanzapine regimen tested here was associated with less than a 15% difference in CR rate compared to a regimen containing fosaprepitant.
This study showed that a regimen based on olanzapine was not inferior to one with fosaprepitant among patients receiving HEC if a less than 15% difference in CR rate is clinically acceptable. Individuals on the olanzapine had a higher prevalence of delayed phase CINV, though those in the olanzapine regimen also did not receive dexamethasone after day 1. The fosaprepitant regimen was much more expensive than the olanzapine regimen, so it may be a good alternative for patients with limited coverage or financial resources. Additional studies are needed to identify the most cost-effective regimens for CINV prevention, and this work needs to also provide greater focus on the prevention of nausea.
Tan, L., Liu, J., Liu, X., Chen, J., Yan, Z., Yang, H., & Zhang, D. (2009). Clinical research of olanzapine for prevention of chemotherapy-induced nausea and vomiting. Journal of Experimental & Clinical Cancer Research, 28, 131.
To evaluate the efficacy and safety of olanzapine compared with 5-hydroxtryptamine3 (5-HT3) receptor antagonists for the prevention of acute and delayed chemotherapy-induced nausea and vomiting (CINV) in patients receiving highly emetogenic chemotherapy (HEC) or moderately emetogenic chemotherapy (MEC) and to evaluate the impact of olanzapine on quality of life (QOL) of those receiving chemotherapy
Patients were randomized into the test group or the control group. On day 1, the test group received 10 mg oral olanzapine, 10 mg IV azasetron, and 10 mg IV dexamethasone; the control group received 10 mg IV azasetron and 10 mg IV dexamethasone. On days 2–5, the test group received 10 mg oral olanzapine and the control group received 10 mg IV dexamethasone. Patients were permitted to take other antiemetic therapy for nausea or emesis based on clinical circumstances. Assessments occurred on days 1–5 post-treatment, and QOL was measure on day 6.
The setting was not identified.
All patients were in active treatment.
This was a randomized controlled trial.
Olanzapine can improve the CR of delayed nausea and vomiting and QOL in patients receiving HEC and MEC.
Olanzapine may be effective in preventing delayed CINV in patients receiving HEC or MEC, but results should be used cautiously because of poor statistical evaluation and reporting.
Wang, X., Wang, L., Wang, H., & Zhang, H. (2015). Effectiveness of olanzapine combined with ondansetron in prevention of chemotherapy-induced nausea and vomiting of non-small cell lung cancer. Cell Biochemistry and Biophysics, 72, 471–473.
To compare the effects of ondansetron and olanzapine to ondansetron alone for management of chemotherapy-induced nausea and vomiting (CINV)
All patients received 8 mg IV ondansetron 30 minutes before chemotherapy. Patients in the experimental group also received 10 mg olanzapine for eight days. CINV was evaluated after one chemotherapy cycle.
PHASE OF CARE: Active antitumor treatment
Randomized, two-group trial
World Health Organization toxicity grading criteria
The incidence of vomiting in the acute phase was 33.33% in the olanzapine group and 54.76% in the control group (p < 0.05). The incidence of delayed CINV was 16.67% with olanzapine and 47.62% in the control group (p < 0.01).
The use of olanzapine as part of an antiemetic regimen was associated with a lower incidence of vomiting in the acute and delayed phases.
This study adds to the body of evidence demonstrating the potential role of olanzapine for control of CINV. Olanzapine may have particular benefit for control in the delayed phase. Nurses need to evaluate the patterns of CINV in patients receiving chemotherapy and can identify patients who may benefit from the use of olanzapine along with other antiemetic agents.
Frame, D.G. (2010). Best practice management of CINV in oncology patients: I. Physiology and treatment of CINV. Multiple neurotransmitters and receptors and the need for combination therapeutic approaches. Journal of Supportive Oncology, 8(2, Suppl. 1), 5–9.
This article demonstrated the importance of combination therapy for prevention and management of CINV. The author provides a good overview of relevant physiology, mechanism of action of current agents, and current regimens used. The article points to the need for additional research with the use of olanzapine for CINV.
National Comprehensive Cancer Network. (2016). NCCN Clinical Practice Guidelines in Oncology: Antiemesis [v.2.2016]. Retrieved from http://www.nccn.org/professionals/physician_gls/pdf/antiemesis.pdf
RESOURCE TYPE: Evidence-based guideline
PHASE OF CARE: Multiple phases of care
One hundred seventy-one articles were retrieved via aPubMed search. No information was provided regarding which articles were selected as relevant to these guidelines, and no discussion of any method used for rating the quality of included evidence exists.
Limited database used. Recommendations are a combination of evidence- and consensus-based suggestions, and most nonpharmacologic interventions are by consensus.
Provides multiple evidence- and consensus-based recommendations for prophylaxis and the management of nausea and vomiting due to chemotherapy or radiation therapy. Recommendations provide a list of chemotherapy agents, including oral agents and categorization as to emetic potential.
Wickham, R. (2010). Best practice management of CINV in oncology patients: II. Antiemetic guidelines and rationale for use. Journal of Supportive Oncology, 8(2, Suppl. 1), 10–15.
The search strategy was not applicable or stated.
This article discussed underlying shared principles in chemotherapy-induced nausea and vomiting (CINV) guidelines from the American Society of Clinical Oncology (ASCO), the Multinational Association for Supportive Care in Cancer (MASCC), and the National Comprehensive Cancer Network (NCCN).
Currently recommended agents for breakthrough CINV are prochlorperazine, metoclopramide with or without diphenhydramine, haloperidol, dexamethasone, dronabinol nabilone, lorazepam, alternating 5-HT3 receptor antagonists, olanzapine, and promethazine. The author noted that guidelines are useful, but guideline adherence can only go to a certain extent in preventing CINV, particularly with delayed symptoms, multiple-day chemotherapeutic regimens, high-dose chemotherapy, breakthrough CINV, and refractory CINV.
CINV guidelines are a good clinical tool to help clinicians implement evidence-based practice; however, their use needs to be accompanied by accurate patient assessments throughout the period of CINV risk. A standard guideline may not fit the needs of all patients and recommendations need to be viewed as a starting point for individualized patient care. More study and attention needs to be given to issues of delayed, breakthrough, and refractory CINV. This article is expert opinion-based and does not provide evidence for all information provided.