Olanzapine is an antipsychotic used in the treatment of schizophrenia and bipolar disorder. Olanzapine has been evaluated as an adjunctive medication for the prevention and treatment of chemotherapy-induced nausea and vomiting (CINV) in patients with cancer. Olanzapine can be used as needed for breakthrough nausea and vomiting associated with chemotherapy
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.
Hocking, C.M., & Kichenadasse, G. (2014). Olanzapine for chemotherapy-induced nausea and vomiting: A systematic review. Supportive Care in Cancer, 22(4), 1143–1151.
PHASE OF CARE: Active antitumor treatment
APPLICATIONS: Palliative care
Per the authors, evidence exists to support olanzapine in highly emetogenic regimens. The Navari (2011) trial was the strongest study to support the use of olanzapine. Toxicity in all included trials demonstrated little side effects. Only one trial described sleepiness during chemotherapy. Olanzapine is a safe and more costly option to use instead of NK-1 antagonists. When used with other antiemetics such as metoclopramide there is a role in prevention, and as a single agent it shows efficacy in delayed CINV as well.
There were only three studies in each group. Only the Shumway trial was double-blinded, but it was a small trial. All the breakthrough trials were by the same investigator and included less than 110 patients.
Olanzapine may have a role in preventing CINV and delayed CINV but there is still limited research. The most recent trial for delayed CINV is a small trial but is double-blinded. Further research is indicated.
Chanthawong, S., Subongkot, S., & Sookprasert, A. (2014). Effectiveness of olanzapine for the treatment of breakthrough chemotherapy induced nausea and vomiting. Journal of the Medical Association of Thailand = Chotmaihet Thangphaet, 97, 349–355.
To evaluate the safety and efficacy of olanzapine for breakthrough emesis in addition to standard antiemetic regimen in patients with cancer receiving highly emetogenic chemotherapy
All patients were treated with the institutional standard for HEC: ondansetron 24 mg IV BID and dexamethasone 10 mg IV BID on day 1. Oral metoclopramide 10 mg TID plus dexamethasone 10 mg po BID were given on days 2 and 3. Oral olanzapine 5 mg was given after the first vomiting episode. Twelve hours later, the second dose was given concurrently with the standard prevention regimen.
Complete response of breakthrough emesis was 60.9%, retching was 71.7%, and nausea was 50.0%. Adverse events were mild, including dizziness, fatigue, and dyspepsia.
The study demonstrated the effectiveness and safety of olanzapine in the treatment of nausea and vomiting in HEC patients. Olanzapine could be considered for treatment of patients at high risk for breakthrough emesis despite standard prevention. Olanzapine 5 mg every 12 hours for at least 24 hours could be recommended per the study.
Olanzapine is a drug that could be extremely helpful in treatment of CINV. Studies have shown olanzapine to be a safe and effective medication in acute and delayed CINV. The reviewed study attempted to show effectiveness in the breakthrough setting but many limitations were reported and are listed above. The researchers should not conduct CINV studies for “breakthrough” if the patient is given suboptimal treatment upfront.
Navari, R.M., Einhorn, L.H., Loehrer, P.J., Sr., Passik, S.D., Vinson, J., McClean, J., … Johnson, C.S. (2007). A phase II trial of olanzapine, dexamethasone, and palonosetron for the prevention of chemotherapy-induced nausea and vomiting: a Hoosier oncology group study. Supportive Care in Cancer, 15, 1285-1291.
To examine the effectiveness of olanzapine in the treatment of chemotherapy-induced nausea and vomiting without the use of dexamethasone after day 1
A 10-mg oral dose of olanzapine was given every day, four times a day for prevention (rather than breakthrough) nausea and vomiting. On day 1 of chemotherapy, patients received 0.25 mg IV palonosetron and dexamethasone (8 mg for moderately emetogenic chemotherapy [MEC], 20 mg for highly emetogenic chemotherapy [HEC]) as well as 10 mg oral olanzapine. On days 2-4, patients received only 10 mg olanzapine daily. The same antiemetic regimen was continued for as many cycles as the patient completed (1-6 cycles). Patients received no other antiemetics on days 2-4. Patients were permitted to take rescue therapy.
The sample consisted of 40 patients who were chemotherapy-naive and receiving HEC or MEC.
This was a prospective, nonrandomized trial with no control or comparison group, consisting of descriptive analysis only (percentage of patients with response described).
Complete response (CR), defined as no emesis and no rescue medications administered and no nausea, was found in 100% of HEC patients and 97% of MEC patients in the acute period (0-24 hours after chemotherapy).
Responses for the delayed period (24-120 hours) decreased. Seventy-five percent of patients reported CR in the delayed and overall periods for emesis and even fewer for control of nausea (50% of HEC patients with CR for nausea and 78% of MEC patients with CR for nausea in the delayed and overall periods). No adverse events to study drugs were noted (no grade 3 or 4 toxicities). Olanzapine was not associated with sedation, weight gain, or hyperglycemia.
Navari, R.M., Nagy, C.K., & Gray, S.E. (2013). The use of olanzapine versus metoclopramide for the treatment of breakthrough chemotherapy-induced nausea and vomiting in patients receiving highly emetogenic chemotherapy. Supportive Care in Cancer, 21, 1655-1663.
To compare the effectiveness of a regimen using olanzapine versus a regimen using metoclopramide for breakthrough chemotherapy-induced nausea and vomiting (CINV) in patients receiving highly emetogenic chemotherapy (HEC)
Patients receiving HEC were randomly assigned to receive either a regimen containing olanzapine or metoclopramide for breakthrough CINV. All patients received prophylactic antiemetics of 12 mg IV dexamethasone, 0.25 mg IV palonosetron, and 150 mg IV fosaprepitant on day 1 prior to chemotherapy. On days 2-4, patients received 4 mg oral dexamethasone, twice per day. The metoclopramide regimen was 10 mg orally every 8 hours for 72 hours. The olanzapine regimen was 10 mg daily for 72 hours.
Those on olanzapine also received placebo once daily so that the number of pills were the same for both groups, so patients were blinded to the study group. Patients were instructed to begin the breakthrough treatment within 30 minutes after any emesis or nausea level greater than 3 on a visual analog scale (VAS). If the breakthrough treatment was begun, patients were to discontinue the oral dexamethasone, notify the on-call nurse, and begin recording nausea and any emesis. Patients were contacted by phone every 24 hours to remind them to complete information and assess toxicities.
The study was conducted at multiple outpatient sites in Indiana.
All patients were in active antitumor treatment.
This was a randomized, parallel group trial.
The M.D. Anderson symptom assessment scale was used.
A total of 39% of patients randomized needed to begin the breakthrough CINV regimen as assigned. Over the 72 hour observation period, 70% of those on olanzapine had no further emesis, compared to 31% of those on metoclopramide (p < 0.01), and 68% on olanzapine had no further nausea, compared to 23% with no nausea in the metoclopramide group (p < 0.01). The pattern of symptom control showed that the incidence of nausea and vomiting declined each study day.
A regimen of breakthrough CINV treatment using olanzapine was more effective than metoclopramide for relief of breakthrough nausea and vomiting in patients receiving HEC.
Olanzapine can be more effective than metoclopramide to manage breakthrough CINV. The breakthrough regimen tested here involved the provision of consistent medication, rather than treatment of each breakthrough episode individually, which may not be the usual approach for management. Findings here showed that about 40% of patients required a breakthrough regimen, despite use of aggressive standard antiemetic therapy. Olanzapine was found to be more effective in relieving nausea, which has been more difficult to effectively control than vomiting. Strong consideration should be given to use of this type of olanzapine regimen and immediate patient-initiated use of such a regimen based on self assessment of CINV severity early in the course of treatment. Most current guidelines provide limited recommendations for breakthrough CINV.
Vig, S., Seibert, L., & Green, M.R. (2014). Olanzapine is effective for refractory chemotherapy-induced nausea and vomiting irrespective of chemotherapy emetogenicity. Journal of Cancer Research and Clinical Oncology, 140(1), 77–82.
To retrospectively evaluate the efficacy of the addition of olanzapine in adults experiencing refractory chemotherapy-induced nausea and vomiting (CINV) stratified by chemotherapy emetogenicity
This was a retrospective chart review of adults receiving chemotherapy between January 2008 and January 2012. Inclusion criteria required that patients received one or more daily doses of olanzapine 10 mg per dose for the indication of refractory CINV during the same admission. Each patient must have received antiemetic prophylaxis and first-line rescue antiemetics appropriate for the emetogenicity level of the chemotherapy regimen according to National Comprehensive Cancer Network guidelines at the time of chemotherapy administration. Patients were excluded if olanzapine was used for anything other than refractory CINV.
Researchers measured the number of rescue antiemetics received following the first dose of olanzapine. Patients were stratified by chemotherapy emetogenicity level, age, gender, and number of prophylactic antiemetics received.
Thirteen women and 10 men were included in this study, the majority of whom were Caucasian (58%) and were most frequently being treated for advanced melanoma (36%) and non-Hodgkin lymphoma (24%). The addition of olanzapine was successful for 65% of patients receiving regimens with low to moderate emetogenicity (n = 23) and 70% of patients receiving regimens with high emetogenicity (n = 10). For these cohorts, olanzapine 5–10 mg was administered for one to eight days (median four days). More women (85%) than men (55%) were successfully treated with the addition of olanzapine. For patients receiving a serotonin antagonist, glucocorticoid, and aprepitant as prophylaxis, the addition of olanzapine was successful for controlling breakthrough nausea 68% of the time. Patients who received a prophylactic serotonin antagonist alone were treated successfully 63% of the time for breakthrough nausea with olanzapine. Cohorts 18 to 50 years old (n = 12) and over 50 years (n = 15) received relief with the addition of olanzapine 67% of the time.
Adding olanzapine contributed to the success of CINV management, particularly for women more often than men. Findings suggest that the addition of olanzapine for refractory to prophylactic and breakthrough antiemetic regimens in all levels of emetogenicity may be beneficial.
Nurses who assess and administer chemotherapy with low to moderate or high levels of emetogenicity should consider the addition of olanzapine for refractory CINV.
Einhorn, L., Rapoport, B., Navari, R., Herrstedt, J., Brames, M., Einhorn, L.H., . . . Brames, M.J. (2017). 2016 updated MASCC/ESMO consensus recommendations: Prevention of nausea and vomiting following multiple-day chemotherapy, high-dose chemotherapy, and breakthrough nausea and vomiting. Supportive Care in Cancer, 25, 303–308.
RESOURCE TYPE: Consensus-based guideline
PROCESS OF DEVELOPMENT: A literature search for papers published between January 1, 2009, and January 6, 2015, related to high-dose chemotherapy, multiple-day chemotherapy regimens, and breakthrough nausea and vomiting
DATABASES USED: PubMed
INCLUSION CRITERIA: Clinical trials, systematic reviews, stem cell transplantations (SCTs), patients with germ cell tumors
EXCLUSION CRITERIA: Other studies
PHASE OF CARE: Active antitumor treatment
Few studies related to the prevention of acute and delayed CINV in patients receiving high-dose and multiple-day chemotherapy regimens and for breakthrough nausea and vomiting. Little evidence related to the control of nausea exists.
Aprepitant should be added to two-drug antiemetic regimens in patients receiving high-dose and multiple-day cisplatin regimens to prevent acute and delayed CINV. Olanzapine is recommended for breakthrough 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.
Roila, F., Herrstedt, J., Aapro, M., Gralla, R.J., Einhorn, L.H., Ballatori, E., … ESMO/MASCC Guidelines Working Group. (2010). Guideline update for MASCC and ESMO in the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting: Results of the Perugia consensus conference. Annals of Oncology, 21(Suppl. 5), v232–v243.
This Perugia consensus panel was composed of 10 committees that reported findings to a 23-member expert panel from 10 different countries. The panel determined level of evidence and made changes in 2004 guidelines if evidence supported a greater than 10% increase in benefit. Updates were approved by the European Society of Medical Oncology (ESMO) Guidelines Working Group. All author relationships were reported. The panel used MEDLINE and other databases, which were not specified.
Emetogenicity of agents:
Prevention of acute CINV:
Prevention of delayed CINV:
Refractory CINV and rescue:
Prevention of anticipatory CINV:
Prevention of CINV with high-dose chemotherapy:
Radiation-induced nausea and vomiting:
Antiemetics in children:
The guidelines provide a clear set of recommendations and review of the relevant evidence strength assessed for various cancer treatment scenarios.
A complete listing of databases used for evidence retrieval was not provided.
Control of emesis has markedly improved in recent years; however, nausea remains a challenge and future research should shift attention to this aspect. Current trials generally define complete response end points that exclude consideration of the experience of nausea rather than vomiting. Trials suggest that some agents are more effective for acute vomiting, others are more effective for delayed vomiting, and some may be more effective for nausea. Identification of these differences and incorporation into the rationale for treatment needs to continue.
Further research is needed in the areas of prevention with high-dose chemotherapy and stem cell support, combined chemotherapy and radiation therapy, and anticipatory nausea and antiemetic use in children. Practitioners need to be aware of the impact of oral therapy and chronic oral chemotherapy treatment on current approaches to antiemetic treatment, timing, and definitions of acute and delayed CINV. Practitioners also need to be aware that current chemotherapy risk determination does not apply to combined radiotherapy and chemotherapy.