OLANZAPINE AND FLUOXETINE

Neuroleptic Malignant Syndrome : Manage with immediate discontinuation and close monitoring (5.3) Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) : Discontinue if DRESS is suspected (5.4) Metabolic Changes : Atypical antipsychotic drugs have been associated with metabolic changes including hyperglycemia, dyslipidemia, and weight gain (5.5) Hyperglycemia and Diabetes Mellitus : In some cases extreme and associated with ketoacidosis or hyperosmolar coma or death. Monitor for symptoms of hyperglycemia. Perform fasting blood glucose testing before beginning, and periodically during treatment. (5.5) Dyslipidemia : Appropriate clinical monitoring is recommended, including fasting blood lipid testing before beginning, and periodically during, treatment (5.5) Weight gain : Consider potential consequences of weight gain. Monitor weight regularly (5.5) Serotonin Syndrome : Serotonin syndrome has been reported with SSRIs and SNRIs, including olanzapine and fluoxetine capsules, both when taken alone, but especially when co-administered with other serotonergic agents (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John's Wort). If such symptoms occur, discontinue olanzapine and fluoxetine capsules and initiate supportive treatment. If concomitant use of olanzapine and fluoxetine capsules with other serotonergic drugs is clinically warranted, patients should be made aware of a potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases (5.6) Angle-Closure Glaucoma : Angle-closure glaucoma has occurred in patients with untreated anatomically narrow angles treated with antidepressants (5.7) Allergic Reactions and Rash : Discontinue upon appearance of rash or allergic phenomena (5.8) Activation of Mania/Hypomania : Screen for Bipolar Disorder and monitor for activation of mania/hypomania (5.9) Tardive Dyskinesia : Discontinue if clinically appropriate (5.10) Orthostatic Hypotension : Can be associated with bradycardia and syncope. Risk is increased during initial dose titration. Use caution in patients with cardiovascular disease or cerebrovascular disease, and those conditions that could affect hemodynamic responses (5.11) Leukopenia, Neutropenia, and Agranulocytosis : Has been reported with antipsychotics, including olanzapine and fluoxetine capsules. Patients with a history of a clinically significant low white blood cell count (WBC) or drug induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy. Consider discontinuing olanzapine and fluoxetine capsules at the first sign of a clinically significant decline in WBC in the absence of other causative factors (5.13) Seizures : Use cautiously in patients with a history of seizures or with conditions that lower the seizure threshold (5.15) Abnormal Bleeding : SSRIs increase the risk of bleeding. Use with NSAIDs, aspirin, warfarin, or other drugs that affect coagulation may potentiate the risk of gastrointestinal or other bleeding (5.16) Hyponatremia : Can occur in association with syndrome of inappropriate antidiuretic hormone (SIADH). Consider discontinuing olanzapine and fluoxetine capsules if symptomatic hyponatremia occurs (SIADH) (5.17) Potential for Cognitive and Motor Impairment : Has potential to impair judgment, thinking, and motor skills. Caution patients about operating machinery (5.18) QT Prolongation : QT prolongation and ventricular arrhythmia including Torsade de Pointes have been reported with fluoxetine. Use with caution in conditions that predispose to arrhythmias or increased fluoxetine exposure. Use cautiously in patients with risk factors for QT prolongation (4.2 , 5.20 ) Hyperprolactinemia : May elevate prolactin levels (5.22) Long Elimination Half-Life of Fluoxetine : Changes in dose will not be fully reflected in plasma for several weeks (5.24) 5.1 Suicidal Thoughts and Behaviors in Children, Adolescents, and Young Adults Patients with Major Depressive Disorder (MDD), both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality) or unusual changes in behavior, whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. Suicide is a known risk of depression and certain other psychiatric disorders, and these disorders themselves are the strongest predictors of suicide. There has been a long-standing concern, however, that antidepressants may have a role in inducing worsening of depression and the emergence of suicidality in certain patients during the early phases of treatment. Pooled analyses of short-term placebo-controlled trials of antidepressant drugs (SSRIs and others) showed that these drugs increase the risk of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults (ages 18 to 24) with Major Depressive Disorder (MDD) and other psychiatric disorders. Short-term studies did not show an increase in the risk of suicidality with antidepressants compared to placebo in adults beyond age 24; there was a reduction with antidepressants compared to placebo in adults aged 65 and older. The pooled analyses of placebo-controlled trials in children and adolescents with MDD, Obsessive Compulsive Disorder (OCD), or other psychiatric disorders included a total of 24 short-term trials of 9 antidepressant drugs in over 4400 patients. The pooled analyses of placebo-controlled trials in adults with MDD or other psychiatric disorders included a total of 295 short-term trials (median duration of 2 months) of 11 antidepressant drugs in over 77,000 patients. There was considerable variation in risk of suicidality among drugs, but a tendency toward an increase in the younger patients for almost all drugs studied. There were differences in absolute risk of suicidality across the different indications, with the highest incidence in MDD. The risk differences (drug versus placebo), however, were relatively stable within age strata and across indications. These risk differences (drug-placebo difference in the number of cases of suicidality per 1000 patients treated) are provided in Table 1. Table 1: Suicidality per 1000 Patients Treated Age Range Drug-Placebo Difference in Number of Cases of Suicidality per 1000 Patients Treated Increases Compared to Placebo <18 14 additional cases 18 to 24 5 additional cases Decreases Compared to Placebo 25 to 64 1 fewer case ≥65 6 fewer cases No suicides occurred in any of the pediatric trials. There were suicides in the adult trials, but the number was not sufficient to reach any conclusion about drug effect on suicide. It is unknown whether the suicidality risk extends to longer-term use, i.e., beyond several months. However, there is substantial evidence from placebo-controlled maintenance trials in adults with depression that the use of antidepressants can delay the recurrence of depression. All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy, or at times of dose changes, either increases or decreases. The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for Major Depressive Disorder as well as for other indications, both psychiatric and nonpsychiatric. Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality. Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms. If the decision has been made to discontinue treatment, medication should be tapered, as rapidly as is feasible, but with recognition that abrupt discontinuation can be associated with certain symptoms [ see Warnings and Precautions ( 5.25 ) ]. Families and caregivers of patients being treated with antidepressants for Major Depressive Disorder or other indications, both psychiatric and nonpsychiatric, should be alerted about the need to monitor patients for the emergence of agitation, irritability, unusual changes in behavior, and the other symptoms described above, as well as the emergence of suicidality, and to report such symptoms immediately to health care providers. Such monitoring should include daily observation by families and caregivers. Prescriptions for olanzapine and fluoxetine capsules should be written for the smallest quantity of capsules consistent with good patient management, in order to reduce the risk of overdose. It should be noted that olanzapine and fluoxetine capsules are not approved for use in treating any indications in patients less than 10 years of age [ see Use in Specific Populations ( 8.4 ) ]. 5.2 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Olanzapine and fluoxetine capsules are not approved for the treatment of patients with dementia-related psychosis [ see Boxed Warning , Warnings and Precautions ( 5.21 ), and Patient Counseling Information ( 17.3 ) ]. In olanzapine placebo-controlled clinical trials of elderly patients with dementia-related psychosis, the incidence of death in olanzapine-treated patients was significantly greater than placebo-treated patients (3.5% vs 1.5%, respectively). Meta-Analysis of Antipsychotic Use in Dementia-Related Psychosis – Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10 week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Olanzapine and fluoxetine capsules are not approved for the treatment of patients with dementia-related psychosis [ see Warnings and Precautions ( 5.21 ) and Patient Counseling Information ( 17.3 ) ]. Cerebrovascular Adverse Events (CVAE), Including Stroke — Cerebrovascular adverse events (e.g., stroke, transient ischemic attack), including fatalities, were reported in patients in trials of olanzapine 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 olanzapine compared to patients treated with placebo. Olanzapine and olanzapine and fluoxetine capsules are not approved for the treatment of patients with dementia-related psychosis [ see Boxed Warning and Patient Counseling Information ( 17.3 ) ]. 5.3 Neuroleptic Malignant Syndrome (NMS) A potentially fatal symptom complex sometimes referred to as NMS has been reported in association with administration of antipsychotic drugs, including olanzapine. 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 both 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 after recovering from NMS, a patient requires treatment with an antipsychotic, the patient should be carefully monitored, since recurrences of NMS have been reported [ see Warnings and Precautions ( 5.5 ) and Patient Counseling Information ( 17.4 , 17.9 ) ]. 5.4 Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) has been reported with olanzapine exposure. DRESS may present with a cutaneous reaction (such as rash or exfoliative dermatitis), eosinophilia, fever, and/or lymphadenopathy with systemic complications such as hepatitis, nephritis, pneumonitis, myocarditis, and/or pericarditis. DRESS is sometimes fatal. Discontinue olanzapine and fluoxetine capsules if DRESS is suspected [see Patient Counseling Information ( 17.5 )]. 5.5 Metabolic Changes Atypical antipsychotic drugs have been associated with metabolic changes including hyperglycemia, dyslipidemia, and weight gain. Metabolic changes may be associated with increased cardiovascular/cerebrovascular risk. Olanzapine’s specific metabolic profile is presented below. Hyperglycemia and Diabetes Mellitus Adults — Physicians should consider the risks and benefits when prescribing olanzapine and fluoxetine capsules to patients with an established diagnosis of diabetes mellitus, or having borderline increased blood glucose level (fasting 100 to 126 mg/dL, nonfasting 140 to 200 mg/dL). Patients taking olanzapine and fluoxetine capsules should be monitored regularly for worsening of glucose control. Patients starting treatment with olanzapine and fluoxetine capsules 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 [see Patient Counseling Information (17.6) ]. Hyperglycemia, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, has been reported in patients treated with atypical antipsychotics, including olanzapine alone, as well as olanzapine taken concomitantly with fluoxetine. 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. Epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse reactions in patients treated with the atypical antipsychotics. While relative risk estimates are inconsistent, the association between atypical antipsychotics and increases in glucose levels appears to fall on a continuum and olanzapine appears to have a greater association than some other atypical antipsychotics. Mean increases in blood glucose have been observed in patients treated (median exposure of 9.2 months) with olanzapine in phase 1 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE). The mean increase of serum glucose (fasting and nonfasting samples) from baseline to the average of the 2 highest serum concentrations was 15.0 mg/dL. In a study of healthy volunteers, subjects who received olanzapine (N=22) for 3 weeks had a mean increase compared to baseline in fasting blood glucose of 2.3 mg/dL. Placebo-treated subjects (N=19) had a mean increase in fasting blood glucose compared to baseline of 0.34 mg/dL. In an analysis of 7 controlled clinical studies, 2 of which were placebo-controlled, with treatment duration up to 12 weeks, olanzapine and fluoxetine capsules were associated with a greater mean change in random glucose compared to placebo (+8.65 mg/dL vs -3.86 mg/dL). The difference in mean changes between olanzapine and fluoxetine capsules and placebo was greater in patients with evidence of glucose dysregulation at baseline (including those patients diagnosed with diabetes mellitus or related adverse reactions, patients treated with anti-diabetic agents, patients with a baseline random glucose level ≥200 mg/dL, or a baseline fasting glucose level ≥126 mg/dL). Olanzapine and fluoxetine capsule-treated patients had a greater mean HbA 1c increase from baseline of 0.15% (median exposure 63 days), compared to a mean HbA 1c decrease of 0.04% in fluoxetine-treated subjects (median exposure 57 days) and a mean HbA 1c increase of 0.12% in olanzapine-treated patients (median exposure 56 days). In an analysis of 6 controlled clinical studies, a larger proportion of olanzapine and fluoxetine capsule-treated subjects had glycosuria (4.4%) compared to placebo-treated subjects (1.4%). The mean change in nonfasting glucose in patients exposed at least 48 weeks was +5.9 mg/dL (N=425). Table 2 shows short-term and long-term changes in random glucose levels from adult olanzapine and fluoxetine capsule studies. Table 2: Changes in Random Glucose Levels from Adult Olanzapine and Fluoxetine Capsule Studies Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm Up to 12 weeks exposure At least 48 weeks exposure N Patients N Patients Random Glucose Normal to High (<140 mg/dL to ≥200 mg/dL) Olanzapine and Fluoxetine Capsules 609 2.3% 382 3.1% Placebo 346 0.3% NA a NA a Borderline to High (≥140 mg/dL and <200 mg/dL to ≥200 mg/dL) Olanzapine and Fluoxetine Capsules 44 34.1% 27 37.0% Placebo 28 3.6% NA a NA a a Not Applicable . In a 47 week olanzapine and fluoxetine capsule study, the mean change from baseline to endpoint in fasting glucose was +4.81 mg/dL (n=130). Table 3 shows the categorical changes in fasting glucose [see Clinical Studies ( 14.2 )]. Table 3: Changes in Fasting Glucose Levels from a Single Adult Olanzapine and Fluoxetine Capsule Study Up to 27 Weeks Exposure (Randomized, Double-Blind Phase) Up to 47 Weeks Exposure Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm N Patients N Patients Fasting Glucose Normal to High (<100 mg/dL to ≥126 mg/dL) Olanzapine and Fluoxetine Capsules 90 4.4% 130 11.5% Fluoxetine 96 5.2% NA a NA a Borderline to High (≥100 mg/dL and <126 mg/dL to ≥126 mg/dL) Olanzapine and Fluoxetine Capsules 98 18.4% 79 32.9% Fluoxetine 97 7.2% NA a NA a a Not Applicable . Controlled fasting glucose data is limited for olanzapine and fluoxetine capsules; however, in an analysis of 5 placebo-controlled olanzapine monotherapy studies with treatment duration up to 12 weeks, olanzapine was associated with a greater mean change in fasting glucose levels compared to placebo (+2.76 mg/dL vs +0.17 mg/dL). The mean change in fasting glucose for olanzapine-treated patients exposed at least 48 weeks was +4.2 mg/dL (N=487). In analyses of patients who completed 9 to 12 months of olanzapine therapy, mean change in fasting and nonfasting glucose levels continued to increase over time. Children and Adolescents — In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for treatment of bipolar I depression in patients 10 to 17 years of age, there were no clinically meaningful differences observed between olanzapine and fluoxetine capsules and placebo for mean change in fasting glucose levels. Table 4 shows categorical changes in fasting blood glucose from the pediatric olanzapine and fluoxetine capsules study. Table 4: Changes in Fasting Glucose Levels from a Single Pediatric Olanzapine and Fluoxetine Capsule Study in Bipolar Depression Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm Up to 8 weeks exposure N Patients Fasting Glucose Normal to High (<100 mg/dL to ≥126 mg/dL) Olanzapine and Fluoxetine Capsules 125 4.8% Placebo 65 1.5% Normal/IGT a to High (<126 mg/dL to ≥126 mg/dL) Olanzapine and Fluoxetine Capsules 156 5.8% Placebo 78 1.3% Normal/IGT (<126 mg/dL) to ≥140 mg/dL) Olanzapine and Fluoxetine Capsules 156 1.9% Placebo 78 0.0% a Impaired Glucose Tolerance. Olanzapine Monotherapy in Adolescents — In an analysis of 3 placebo-controlled olanzapine monotherapy studies of adolescent patients, including those with Schizophrenia (6 weeks) or Bipolar I Disorder (manic or mixed episodes) (3 weeks), olanzapine was associated with a greater mean change from baseline in fasting glucose levels compared to placebo (+2.68 mg/dL vs -2.59 mg/dL). The mean change in fasting glucose for adolescents exposed at least 24 weeks was +3.1 mg/dL (N=121). Table 5 shows short-term and long-term changes in fasting blood glucose from adolescent olanzapine monotherapy studies. Table 5: Changes in Fasting Glucose Levels from Adolescent Olanzapine Monotherapy Studies Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm Up to 12 weeks exposure At least 24 weeks exposure N Patients N Patients Fasting Glucose Normal to High (<100 mg/dL to ≥126 mg/dL) Olanzapine 124 0% 108 0.9% Placebo 53 1.9% NA a NA a Borderline to High (≥100 mg/dL and <126 mg/dL to ≥126 mg/dL) Olanzapine 14 14.3% 13 23.1% Placebo 13 0% NA a NA a a Not Applicable. Dyslipidemia Undesirable alterations in lipids have been observed with olanzapine and fluoxetine capsule use. Clinical monitoring, including baseline and periodic follow-up lipid evaluations in patients using olanzapine and fluoxetine capsules, is recommended [see Patient Counseling Information ( 17.7 )]. Adults — Clinically meaningful, and sometimes very high (>500 mg/dL), elevations in triglyceride levels have been observed with olanzapine and fluoxetine capsule use. Clinically meaningful increases in total cholesterol have also been seen with olanzapine and fluoxetine capsule use. In an analysis of 7 controlled clinical studies, 2 of which were placebo-controlled, with treatment duration up to 12 weeks, olanzapine and fluoxetine capsule-treated patients had an increase from baseline in mean random total cholesterol of 12.1 mg/dL compared to an increase from baseline in mean random total cholesterol of 4.8 mg/dL for olanzapine-treated patients and a decrease in mean random total cholesterol of 5.5 mg/dL for placebo-treated patients. Table 6 shows categorical changes in nonfasting lipid values. In long-term olanzapine and fluoxetine in combination studies (at least 48 weeks), changes (at least once) in nonfasting total cholesterol from normal at baseline to high occurred in 12% (N=150) and changes from borderline to high occurred in 56.6% (N=143) of patients. The mean change in nonfasting total cholesterol was 11.3 mg/dL (N=426). Table 6: Changes in Nonfasting Lipids Values from Controlled Clinical Studies with Treatment Duration up to 12 Weeks Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm N Patients Nonfasting Triglycerides Increase by ≥50 mg/dL OFC 174 67.8% Olanzapine 172 72.7% Normal to High (<150 mg/dL to ≥500 mg/dL) OFC 57 0% Olanzapine 58 0% Borderline to High (≥150 mg/dL and <500 mg/dL to ≥500 mg/dL) OFC 106 15.1% Olanzapine 103 8.7% Nonfasting Total Cholesterol Increase by ≥40 mg/dL OFC 685 35% Olanzapine 749 22.7% Placebo 390 9% Normal to High (<200 mg/dL to ≥240 mg/dL) OFC 256 8.2% Olanzapine 279 2.9% Placebo 175 1.7% Borderline to High (≥200 mg/dL and <240 mg/dL to ≥240 mg/dL) OFC 213 36.2% Olanzapine 261 27.6% Placebo 111 9.9% A 47 week olanzapine and fluoxetine capsule study demonstrated mean changes from baseline to endpoint in fasting total cholesterol (+1.24 mg/dL), LDL cholesterol (+0.29 mg/dL), direct HDL cholesterol (-2.13 mg/dL), and triglycerides (+11.33 mg/dL). Table 7 shows the categorical changes in fasting lipids [see Clinical Studies ( 14.2 )]. Table 7: Changes in Fasting Lipids Values from a Controlled Study with Olanzapine and Fluoxetine Capsule Treatment Duration up to 47 Weeks Up to 27 Weeks Treatment (Randomized, Double-Blind Phase) Up to 47 Weeks Treatment Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm N Patients N Patients Fasting Total Cholesterol Normal to High (<200 mg/dL to ≥240 mg/dL) Olanzapine and Fluoxetine Capsules 47 2.1% 83 19.3% Fluoxetine 59 3.4% NA a NA a Borderline to High (≥200 and <240 mg/dL to ≥240 mg/dL) Olanzapine and Fluoxetine Capsules 75 28.0% 73 69.9% Fluoxetine 83 20.5% NA a NA a Fasting LDL Cholesterol Normal to High (<100 mg/dL to ≥160 mg/dL) Olanzapine and Fluoxetine Capsules 22 4.5% 46 8.7% Fluoxetine 26 0% NA a NA a Borderline to High (≥100 mg/dL and <160 mg/dL to ≥160 mg/dL) Olanzapine and Fluoxetine Capsules 115 17.4% 128 46.9% Fluoxetine 134 10.4% NA a NA a Fasting HDL Cholesterol Normal to Low (≥40 mg/dL to <40 mg/dL) Olanzapine and Fluoxetine Capsules 199 39.2% 193 45.1% Fluoxetine 208 25.5% NA a NA a Fasting Triglycerides Normal to High (<150 mg/dL to ≥200 mg/dL) Olanzapine and Fluoxetine Capsules 68 16.2% 115 46.1% Fluoxetine 74 5.4% NA a NA a Borderline to High (≥150 mg/dL and <200 mg/dL to ≥200 mg/dL) Olanzapine and Fluoxetine Capsules 47 51.1% 40 72.5% Fluoxetine 41 26.8% NA a NA a a Not Applicable. Fasting lipid data is limited for olanzapine and fluoxetine capsules; however, in an analysis of 5 placebo-controlled olanzapine monotherapy studies with treatment duration up to 12 weeks, olanzapine-treated patients had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.3 mg/dL, 3.0 mg/dL, and 20.8 mg/dL respectively compared to decreases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 6.1 mg/dL, 4.3 mg/dL, and 10.7 mg/dL for placebo-treated patients. For fasting HDL cholesterol, no clinically meaningful differences were observed between olanzapine-treated patients and placebo-treated patients. Mean increases in fasting lipid values (total cholesterol, LDL cholesterol, and triglycerides) were greater in patients without evidence of lipid dysregulation at baseline, where lipid dysregulation was defined as patients diagnosed with dyslipidemia or related adverse reactions, patients treated with lipid lowering agents, patients with high baseline lipid levels. In long-term olanzapine studies (at least 48 weeks), patients had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.6 mg/dL, 2.5 mg/dL, and 18.7 mg/dL, respectively, and a mean decrease in fasting HDL cholesterol of 0.16 mg/dL. In an analysis of patients who completed 12 months of therapy, the mean nonfasting total cholesterol did not increase further after approximately 4 to 6 months. The proportion of olanzapine-treated patients who had changes (at least once) in total cholesterol, LDL cholesterol or triglycerides from normal or borderline to high, or changes in HDL cholesterol from normal or borderline to low, was greater in long-term studies (at least 48 weeks) as compared with short-term studies. Table 8 shows categorical changes in fasting lipids values. Table 8: Changes in Fasting Lipids Values from Adult Olanzapine Monotherapy Studies Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm Up to 12 weeks exposure At least 48 weeks exposure N Patients N Patients Fasting Triglycerides Increase by ≥50 mg/dL Olanzapine 745 39.6% 487 61.4% Placebo 402 26.1% NA a NA a Normal to High (<150 mg/dL to ≥200 mg/dL) Olanzapine 457 9.2% 293 32.4% Placebo 251 4.4% NA a NA a Borderline to High (≥150 mg/dL and <200 mg/dL to ≥200 mg/dL) Olanzapine 135 39.3% 75 70.7% Placebo 65 20.0% NA a NA a Fasting Total Cholesterol Increase by ≥40 mg/dL Olanzapine 745 21.6% 489 32.9% Placebo 402 9.5% NA a NA a Normal to High (<200 mg/dL to ≥240 mg/dL) Olanzapine 392 2.8% 283 14.8% Placebo 207 2.4% NA a NA a Borderline to High (≥200 mg/dL and <240 mg/dL to ≥240 mg/dL) Olanzapine 222 23.0% 125 55.2% Placebo 112 12.5% NA a NA a Fasting LDL Cholesterol Increase by ≥30 mg/dL Olanzapine 536 23.7% 483 39.8% Placebo 304 14.1% NA a NA a Normal to High (<100 mg/dL to ≥160 mg/dL) Olanzapine 154 0% 123 7.3% Placebo 82 1.2% NA a NA a Borderline to High (≥100 mg/dL and <160 mg/dL to ≥160 mg/dL) Olanzapine 302 10.6% 284 31.0% Placebo 173 8.1% NA a NA a a Not Applicable. In phase 1 of the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), over a median exposure of 9.2 months, the mean increase in triglycerides in patients taking olanzapine was 40.5 mg/dL. In phase 1 of CATIE, the median increase in total cholesterol was 9.4 mg/dL. Children and Adolescents — In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for treatment of bipolar I depression in patients 10 to 17 years of age, there were clinically meaningful and statistically significant differences observed between olanzapine and fluoxetine capsules and placebo for mean change in fasting total cholesterol (+16.3 mg/dL vs. -4.3 mg/dL, respectively), LDL cholesterol (+9.7 mg/dL vs -3.5 mg/dL, respectively), and triglycerides (+35.4 mg/dL vs. -3.5 mg/dL, respectively). The magnitude and frequency of changes in lipids were greater in children and adolescents than previously observed in adults. Table 9 shows categorical changes in fasting lipids values from the pediatric olanzapine and fluoxetine capsules study. Table 9: Changes in Fasting Lipids Values from a Single Pediatric Olanzapine and Fluoxetine Capsule Study in Bipolar Depression Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm Up to 8 weeks exposure N Patients Fasting Triglycerides Increase by ≥50 mg/dL OFC 158 70.3% Placebo 81 38.3% Normal to High (<90 mg/dL to ≥130 mg/dL) OFC 71 39.4% Placebo 31 19.4% Borderline to High (≥90 mg/dL and <130 mg/dL to ≥130 mg/dL) OFC 13 84.6% Placebo 12 33.3% Normal/borderline to High (<130 mg/dL to ≥130 mg/dL) OFC 106 52.8% Placebo 56 25.0% Normal to borderline/high (<90 mg/dL to ≥90 mg/dL) OFC 71 73.2% Placebo 31 41.9% Normal/borderline/high to very high (<500 mg/dL to ≥500 mg/dL) OFC 158 2.5% Placebo 81 1.2% Fasting Total Cholesterol Increase by ≥40 mg/dL OFC 158 52.5% Placebo 81 8.6% Normal to High (<170 mg/dL to ≥200 mg/dL) OFC 81 12.3% Placebo 44 4.5% Borderline to High (≥170 mg/dL and <200 mg/dL to ≥200 mg/dL) OFC 22 72.7% Placebo 11 24.3% Normal/borderline to High (<200 mg/dL to ≥200 mg/dL) OFC 126 32.5% Placebo 67 10.4% Normal to borderline/high (<170 mg/dL to ≥170 mg/dL) OFC 81 58.0% Placebo 44 31.8% Fasting LDL Cholesterol Increase by ≥30 mg/dL OFC 158 53.8% Placebo 81 23.5% Normal to High (<110 mg/dL to ≥130 mg/dL) OFC 112 13.4% Placebo 62 6.5% Borderline to High (≥110 mg/dL and <130 mg/dL to ≥130 mg/dL) OFC 12 75.0% Placebo 3 0.0% Normal/borderline to High (<130 mg/dL to ≥130 mg/dL) OFC 138 21.7% Placebo 77 7.8% Normal to borderline/high (<110 mg/dL to ≥110 mg/dL) OFC 112 30.4% Placebo 62 14.5% Olanzapine Monotherapy in Adolescents — In an analysis of 3 placebo-controlled olanzapine monotherapy studies of adolescents, including those with Schizophrenia (6 weeks) or Bipolar I Disorder (manic or mixed episodes) (3 weeks), olanzapine-treated adolescents had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 12.9 mg/dL, 6.5 mg/dL, and 28.4 mg/dL, respectively, compared to increases from baseline in mean fasting total cholesterol and LDL cholesterol of 1.3 mg/dL and 1.0 mg/dL, and a decrease in triglycerides of 1.1 mg/dL for placebo-treated adolescents. For fasting HDL cholesterol, no clinically meaningful differences were observed between olanzapine-treated adolescents and placebo-treated adolescents. In long-term olanzapine studies (at least 24 weeks), adolescents had increases from baseline in mean fasting total cholesterol, LDL cholesterol, and triglycerides of 5.5 mg/dL, 5.4 mg/dL, and 20.5 mg/dL, respectively, and a mean decrease in fasting HDL cholesterol of 4.5 mg/dL. Table 10 shows categorical changes in fasting lipids values in adolescents. Table 10: Changes in Fasting Lipids Values from Adolescent Olanzapine Monotherapy Studies Laboratory Analyte Category Change (at least once) from Baseline Treatment Arm Up to 6 weeks exposure At least 24 weeks exposure N Patients N Patients Fasting Triglycerides Increase by ≥50 mg/dL Olanzapine 138 37.0% 122 45.9% Placebo 66 15.2% NA a NA a Normal to High (<90 mg/dL to >130 mg/dL) Olanzapine 67 26.9% 66 36.4% Placebo 28 10.7% NA a NA a Borderline to High (≥90 mg/dL and ≤130 mg/dL to >130 mg/dL) Olanzapine 37 59.5% 31 64.5% Placebo 17 35.3% NA a NA a Fasting Total Cholesterol Increase by ≥40 mg/dL Olanzapine 138 14.5% 122 14.8% Placebo 66 4.5% NA a NA a Normal to High (<170 mg/dL to ≥200 mg/dL) Olanzapine 87 6.9% 78 7.7% Placebo 43 2.3% NA a NA a Borderline to High (≥170 mg/dL and <200 mg/dL to ≥200 mg/dL) Olanzapine 36 38.9% 33 57.6% Placebo 13 7.7% NA a NA a Fasting LDL Cholesterol Increase by ≥30 mg/dL Olanzapine 137 17.5% 121 22.3% Placebo 63 11.1% NA a NA a Normal to High (<110 mg/dL to ≥130 mg/dL) Olanzapine 98 5.1% 92 10.9% Placebo 44 4.5% NA a NA a Borderline to High (≥110 mg/dL and <130 mg/dL to ≥130 mg/dL) Olanzapine 29 48.3% 21 47.6% Placebo 9 0% NA a NA a a Not Applicable. Weight Gain Potential consequences of weight gain should be considered prior to starting olanzapine and fluoxetine capsules. Patients receiving olanzapine and fluoxetine capsules should receive regular monitoring of weight [ see Patient Counseling Information ( 17.8 ) ]. Adults — In an analysis of 7 controlled clinical studies, 2 of which were placebo-controlled, the mean weight increase for olanzapine and fluoxetine capsule-treated patients was greater than placebo-treated patients [4 kg (8.8 lb) vs -0.3 kg (-0.7 lb)]. Twenty-two percent of olanzapine and fluoxetine capsule-treated patients gained at least 7% of their baseline weight, with a median exposure to event of 6 weeks. This was greater than in placebo-treated patients (1.8%). Approximately 3% of olanzapine and fluoxetine capsule-treated patients gained at least 15% of their baseline weight, with a median exposure to event of 8 weeks. This was greater than in placebo-treated patients (0%). Clinically significant weight gain was observed across all baseline Body Mass Index (BMI) categories. Discontinuation due to weight gain occurred in 2.5% of olanzapine and fluoxetine capsule-treated patients and 0% of placebo-treated patients. In long-term olanzapine and fluoxetine in combination studies (at least 48 weeks), the mean weight gain was 6.7 kg (14.7 lb) (median exposure of 448 days, N=431). The percentages of patients who gained at least 7%, 15% or 25% of their baseline body weight with long-term exposure were 66%, 33%, and 10%, respectively. Discontinuation due to weight gain occurred in 1.2% of patients treated with olanzapine and fluoxetine in combination following at least 48 weeks of exposure. Table 11 presents the distribution of weight gain in a single long-term relapse prevention study of patients treated for up to 47 weeks with olanzapine and fluoxetine [see Clinical Studies (14.2) ]. Table 11: Weight Gain with Olanzapine and Fluoxetine Use in a Single Relapse Prevention Study in Adults Amount Gained kg (lb) Up to 8 Weeks (N=881) (%) Up to 20 Weeks (N=651) (%) Up to 47 Weeks (N=220) (%) ≤0 19.8 14.9 19.1 0 to ≤5 (0 to 11 lb) 64.1 47.2 37.7 >5 to ≤10 (11 to 22 lb) 15.1 30.3 27.7 >10 to ≤15 (22 to 33 lb) 0.9 5.8 10.0 >15 to ≤20 (33 to 44 lb) 0.1 1.2 3.2 >20 to ≤25 (44 to 55 lb) 0.0 0.6 1.4 >25 to ≤30 (55 to 66 lb) 0.0 0.0 0.5 >30 (>66 lb) 0.0 0.0 0.5 In long-term olanzapine studies (at least 48 weeks), the mean weight gain was 5.6 kg (12.3 lb) (median exposure of 573 days, N=2021). The percentages of patients who gained at least 7%, 15%, or 25% of their baseline body weight with long-term exposure were 64%, 32%, and 12%, respectively. Discontinuation due to weight gain occurred in 0.4% of olanzapine-treated patients following at least 48 weeks of exposure. Table 12 includes data on adult weight gain with olanzapine pooled from 86 clinical trials. The data in each column represent data for those patients who completed treatment periods of the durations specified. Table 12: Weight Gain with Olanzapine Use in Adults Amount Gained kg (lb) 6 Weeks (N=7465) (%) 6 Months (N=4162) (%) 12 Months (N=1345) (%) 24 Months (N=474) (%) 36 Months (N=147) (%) ≤0 26.2 24.3 20.8 23.2 17.0 0 to ≤5 (0 to 11 lb) 57.0 36.0 26.0 23.4 25.2 >5 to ≤10 (11 to 22 lb) 14.9 24.6 24.2 24.1 18.4 >10 to ≤15 (22 to 33 lb) 1.8 10.9 14.9 11.4 17.0 >15 to ≤20 (33 to 44 lb) 0.1 3.1 8.6 9.3 11.6 >20 to ≤25 (44 to 55 lb) 0 0.9 3.3 5.1 4.1 >25 to ≤30 (55 to 66 lb) 0 0.2 1.4 2.3 4.8 >30 (>66 lb) 0 0.1 0.8 1.2 2 Dose group differences with respect to weight gain have been observed. In a single 8 week randomized, double-blind, fixed-dose study comparing 10 (N=199), 20 (N=200) and 40 (N=200) mg/day of oral olanzapine in adult patients with schizophrenia or schizoaffective disorder, mean baseline to endpoint increase in weight (10 mg/day: 1.9 kg; 20 mg/day: 2.3 kg; 40 mg/day: 3 kg) was observed with significant differences between 10 vs 40 mg/day. Children and Adolescents — In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for the treatment of bipolar I depression in patients 10 to 17 years of age, olanzapine and fluoxetine capsules were associated with greater mean change in weight compared to placebo (+4.4 kg vs +0.5 kg, respectively). The percentages of children and adolescents who gained at least 7%, 15%, or 25% of their baseline body weight with 8 week exposure were 52%, 14%, and 1%, respectively. The proportion of patients who had clinically significant weight gain was greater in children and adolescent patients compared to short-term data in adults. Discontinuation due to weight gain occurred in 2.9% of olanzapine and fluoxetine capsule-treated patients and 0% of placebo-treated patients. Table 13 depicts weight gain observed in the pediatric olanzapine and fluoxetine capsule study. Table 13: Weight Gain with OFC Use Seen in a Single Pediatric Study in Bipolar Depression Amount Gained kg (lb) Up to 8 Weeks (N=170) (%) ≤0 7.1 0 to ≤5 (0 to 11 lb) 54.7 >5 to ≤10 (11 to 22 lb) 31.2 >10 to ≤15 (22 to 33 lb) 7.1 >15 to ≤20 (33 to 44 lb) 0 >20 to ≤25 (44 to 55 lb) 0 >25 to ≤30 (55 to 66 lb) 0 >30 (>66 lb) 0 Olanzapine Monotherapy in Adolescents — Mean increase in weight in adolescents was greater than in adults. In 4 placebo-controlled trials, discontinuation due to weight gain occurred in 1% of olanzapine-treated patients, compared to 0% of placebo-treated patients. Table 14: Weight Gain with Olanzapine Use in Adolescents from 4 Placebo-Controlled Trials Mean change in body weight from baseline (median exposure = 3 weeks) Olanzapine-treated patients Placebo-treated patients 4.6 kg (10.1 lb) 0.3 kg (0.7 lb) Percentage of patients who gained at least 7% of baseline body weight 40.6% (median exposure to 7% = 4 weeks) 9.8% (median exposure to 7% = 8 weeks) Percentage of patients who gained at least 15% of baseline body weight 7.1% (median exposure to 15% = 19 weeks) 2.7% (median exposure to 15% = 8 weeks) In long-term olanzapine studies (at least 24 weeks), the mean weight gain was 11.2 kg (24.6 lb) (median exposure of 201 days, N=179). The percentages of adolescents who gained at least 7%, 15%, or 25% of their baseline body weight with long-term exposure were 89%, 55%, and 29%, respectively. Among adolescent patients, mean weight gain by baseline BMI category was 11.5 kg (25.3 lb), 12.1 kg (26.6 lb), and 12.7 kg (27.9 lb), respectively, for normal (N=106), overweight (N=26) and obese (N=17). Discontinuation due to weight gain occurred in 2.2% of olanzapine-treated patients following at least 24 weeks of exposure. Table 15 shows data on adolescent weight gain with olanzapine pooled from 6 clinical trials. The data in each column represent data for those patients who completed treatment periods of the durations specified. Little clinical trial data is available on weight gain in adolescents with olanzapine beyond 6 months of treatment. Table 15: Weight Gain with Olanzapine Use in Adolescents Amount Gained kg (lb) 6 Weeks (N=243) (%) 6 Months (N=191) (%) ≤0 2.9 2.1 0 to ≤5 (0 to 11 lb) 47.3 24.6 >5 to ≤10 (11 to 22 lb) 42.4 26.7 >10 to ≤15 (22 to 33 lb) 5.8 22.0 >15 to ≤20 (33 to 44 lb) 0.8 12.6 >20 to ≤25 (44 to 55 lb) 0.8 9.4 >25 to ≤30 (55 to 66 lb) 0 2.1 >30 to ≤35 (66 to 77 lb) 0 0 >35 to ≤40 (77 to 88 lb) 0 0 >40 (>88 lb) 0 0.5 5.6 Serotonin Syndrome The development of a potentially life-threatening serotonin syndrome has been reported with SNRIs and SSRIs, including olanzapine and fluoxetine capsules, alone but particularly with concomitant use of other serotonergic drugs (including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, tryptophan, buspirone, amphetamines, and St. John's Wort) and with drugs that impair metabolism of serotonin (in particular, MAOIs, both those intended to treat psychiatric disorders and also others, such as linezolid and intravenous methylene blue). Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Patients should be monitored for the emergence of serotonin syndrome. Serotonin syndrome symptoms may include mental status changes (e.g., agitation, hallucinations, delirium, and coma), autonomic instability (e.g., tachycardia, labile blood pressure, dizziness, diaphoresis, flushing, hyperthermia), neuromuscular symptoms (e.g., tremor, rigidity, myoclonus, hyperreflexia, incoordination), seizures, and/or gastrointestinal symptoms (e.g., nausea, vomiting, diarrhea). Patients should be monitored for the emergence of serotonin syndrome. The concomitant use of olanzapine and fluoxetine capsules with MAOIs intended to treat psychiatric disorders is contraindicated. Olanzapine and fluoxetine capsules should also not be started in a patient who is being treated with MAOIs such as linezolid or intravenous methylene blue. All reports with methylene blue that provided information on the route of administration involved intravenous administration in the dose range of 1 mg/kg to 8 mg/kg. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection) or at lower doses. There may be circumstances when it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in a patient taking olanzapine and fluoxetine capsules. Olanzapine and fluoxetine capsules should be discontinued before initiating treatment with the MAOI [ ]. The concomitant use of olanzapine and fluoxetine capsules with MAOIs intended to treat psychiatric disorders is contraindicated. Olanzapine and fluoxetine capsules should also not be started in a patient who is being treated with MAOIs such as linezolid or intravenous methylene blue. All reports with methylene blue that provided information on the route of administration involved intravenous administration in the dose range of 1 mg/kg to 8 mg/kg. No reports involved the administration of methylene blue by other routes (such as oral tablets or local tissue injection) or at lower doses. There may be circumstances when it is necessary to initiate treatment with an MAOI such as linezolid or intravenous methylene blue in a patient taking olanzapine and fluoxetine capsules. Olanzapine and fluoxetine capsules should be discontinued before initiating treatment with the MAOI [ see Dosage and Administration ( 2.4 , 2.5 ) and Contraindications ( 4.1 ) ]. If concomitant use of olanzapine and fluoxetine capsules with other serotonergic drugs including triptans, tricyclic antidepressants, fentanyl, lithium, tramadol, buspirone, tryptophan, amphetamines, and St. John's Wort is clinically warranted, patients should be made aware of a potential increased risk for serotonin syndrome, particularly during treatment initiation and dose increases. Treatment with olanzapine and fluoxetine capsules and any concomitant serotonergic agents should be discontinued immediately if the above events occur and supportive symptomatic treatment should be initiated.Treatment with olanzapine and fluoxetine capsules and any concomitant serotonergic agents should be discontinued immediately if the above events occur and supportive symptomatic treatment should be initiated. 5.7 Angle-Closure Glaucoma Angle-Closure Glaucoma — The pupillary dilation that occurs following use of many antidepressant drugs including olanzapine and fluoxetine capsules may trigger an angle-closure attack in a patient with anatomically narrow angles who does not have a patent iridectomy. 5.8 Allergic Reactions and Rash In olanzapine and fluoxetine capsule premarketing controlled clinical studies, the overall incidence of rash or allergic reactions in olanzapine and fluoxetine capsule-treated patients [4.6% (26/571)] was similar to that of placebo [5.2% (25/477)]. The majority of the cases of rash and/or urticaria were mild; however, 3 patients discontinued (1 due to rash, which was moderate in severity and 2 due to allergic reactions, 1 of which included face edema). In fluoxetine U.S. clinical studies, 7% of 10,782 fluoxetine-treated patients developed various types of rashes and/or urticaria. Among the cases of rash and/or urticaria reported in premarketing clinical studies, almost a third were withdrawn from treatment because of the rash and/or systemic signs or symptoms associated with the rash. Clinical findings reported in association with rash include fever, leukocytosis, arthralgias, edema, carpal tunnel syndrome, respiratory distress, lymphadenopathy, proteinuria, and mild transaminase elevation. Most patients improved promptly with discontinuation of fluoxetine and/or adjunctive treatment with antihistamines or steroids, and all patients experiencing these reactions were reported to recover completely. In fluoxetine premarketing clinical studies, 2 patients are known to have developed a serious cutaneous systemic illness. In neither patient was there an unequivocal diagnosis, but 1 was considered to have a leukocytoclastic vasculitis, and the other, a severe desquamating syndrome that was considered variously to be a vasculitis or erythema multiforme. Other patients have had systemic syndromes suggestive of serum sickness. Since the introduction of fluoxetine, systemic reactions, possibly related to vasculitis, have developed in patients with rash. Although these reactions are rare, they may be serious, involving the lung, kidney, or liver. Death has been reported to occur in association with these systemic reactions. Anaphylactoid reactions, including bronchospasm, angioedema, and urticaria alone and in combination, have been reported. Pulmonary reactions, including inflammatory processes of varying histopathology and/or fibrosis, have been reported rarely. These reactions have occurred with dyspnea as the only preceding symptom. Whether these systemic reactions and rash have a common underlying cause or are due to different etiologies or pathogenic processes is not known. Furthermore, a specific underlying immunologic basis for these reactions has not been identified. Upon the appearance of rash or of other possible allergic phenomena for which an alternative etiology cannot be identified, olanzapine and fluoxetine capsules should be discontinued. 5.9 Activation of Mania/Hypomania A major depressive episode may be the initial presentation of Bipolar Disorder. It is generally believed (though not established in controlled trials) that treating such an episode with an antidepressant alone may increase the likelihood of precipitation of a manic episode in patients at risk for Bipolar Disorder. Whether any of the symptoms described for clinical worsening and suicide risk represent such a conversion is unknown . However, prior to initiating treatment with an antidepressant, patients with depressive symptoms should be adequately screened to determine if they are at risk for Bipolar Disorder; such screening should include a detailed psychiatric history, including a family history of suicide, Bipolar Disorder, and depression. It should be noted that olanzapine and fluoxetine capsules are approved for the acute treatment of depressive episodes associated with Bipolar I Disorder. In the 3 controlled bipolar depression studies (2 in adults and 1 in children and adolescents [10 to 17 years of age]) there was no statistically significant difference in the incidence of manic reactions (manic reaction or manic depressive reaction) between olanzapine and fluoxetine capsule- and placebo-treated patients. In 1 adult study, the incidence of manic reactions was (7% [3/43]) in olanzapine and fluoxetine capsule-treated patients compared to (3% [5/184]) in placebo-treated patients. In the other adult study, the incidence of manic reactions was (2% [1/43]) in olanzapine and fluoxetine capsule-treated patients compared to (8% [15/193]) in placebo-treated patients. In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for the treatment of bipolar I depression in patients 10 to 17 years of age, the incidence of manic reactions was (1% [2/170]) in olanzapine and fluoxetine capsule-treated patients compared to (0% [0/84]) in placebo-treated patients. Because of the cyclical nature of Bipolar I Disorder, patients should be monitored closely for the development of symptoms of mania/hypomania during treatment with olanzapine and fluoxetine capsules. 5.10 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 or may even arise after discontinuation of treatment. 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 the 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. The incidence of dyskinetic movement in olanzapine and fluoxetine capsule-treated patients was infrequent. The mean score on the Abnormal Involuntary Movement Scale (AIMS) in the olanzapine and fluoxetine capsule-controlled database across clinical studies involving olanzapine and fluoxetine capsule-treated patients decreased from baseline. Nonetheless, olanzapine and fluoxetine capsules should be prescribed in a manner that is most likely to minimize the risk of tardive dyskinesia. If signs and symptoms of tardive dyskinesia appear in a patient on olanzapine and fluoxetine capsules, drug discontinuation should be considered. However, some patients may require treatment with olanzapine and fluoxetine capsules despite the presence of the syndrome. The need for continued treatment should be reassessed periodically. 5.11 Orthostatic Hypotension Olanzapine and fluoxetine capsules may induce orthostatic hypotension associated with dizziness, tachycardia, bradycardia and, in some patients, syncope, especially during the initial dose-titration period [ see Patient Counseling Information ( 17.12 ) ]. In the olanzapine and fluoxetine capsule-controlled clinical trials across all indications, there were no significant differences between olanzapine and fluoxetine capsule-treated patients and olanzapine, fluoxetine- or placebo-treated patients in exposure-adjusted rates of orthostatic systolic blood pressure decreases of at least 30 mm Hg. Orthostatic systolic blood pressure decreases of at least 30 mm Hg occurred in 4.0% (28/705), 2.3% (19/831), 4.5% (18/399), and 1.8% (8/442) of the olanzapine and fluoxetine capsules, olanzapine, fluoxetine, and placebo groups, respectively. In this group of studies, the incidence of syncope-related adverse reactions (i.e., syncope and/or loss of consciousness) in olanzapine and fluoxetine capsule-treated patients was 0.4% (3/771) compared to placebo 0.2% (1/477). In a clinical pharmacology study of olanzapine and fluoxetine capsules, 3 healthy subjects were discontinued from the trial after experiencing severe, but self-limited, hypotension and bradycardia that occurred 2 to 9 hours following a single 12 mg/50 mg dose of olanzapine and fluoxetine capsules. Reactions consisting of this combination of hypotension and bradycardia (and also accompanied by sinus pause) have been observed in at least 3 other healthy subjects treated with various formulations of olanzapine (1 oral, 2 intramuscular). In controlled clinical studies, the incidence of patients with a ≥20 bpm decrease in orthostatic pulse concomitantly with a ≥20 mm Hg decrease in orthostatic systolic blood pressure was 0.3% (2/706) in the olanzapine and fluoxetine capsule group, 0.2% (1/445) in the placebo group, 0.7% (6/837) in the olanzapine group, and 0% (0/404) in the fluoxetine group. Olanzapine and fluoxetine capsules 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, or conditions that would predispose patients to hypotension (dehydration, hypovolemia, and treatment with antihypertensive medications). 5.12 Falls Olanzapine and fluoxetine capsules may cause somnolence, postural hypotension, motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries. For patients with diseases, conditions, or medications that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic treatment and recurrently for patients on long-term antipsychotic therapy. 5.13 Leukopenia, Neutropenia, and Agranulocytosis Class Effect — In clinical trial and/or postmarketing experience, events of leukopenia/neutropenia have been reported temporally related to antipsychotic agents, including olanzapine and fluoxetine capsules. Agranulocytosis has also been reported. Possible risk factors for leukopenia/neutropenia include preexisting low white blood cell count (WBC) and history of drug induced leukopenia/neutropenia. Patients with a history of a clinically significant low WBC or drug induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy and discontinuation of olanzapine and fluoxetine capsules should be considered at the first sign of a clinically significant decline in WBC in the absence of other causative factors. Patients with clinically significant neutropenia should be carefully monitored for fever or other symptoms or signs of infection and treated promptly if such symptoms or signs occur. Patients with severe neutropenia (absolute neutrophil count <1000/mm 3 ) should discontinue olanzapine and fluoxetine capsules and have their WBC followed until recovery. 5.14 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. Olanzapine and fluoxetine capsules are not approved for the treatment of patients with Alzheimer’s disease. 5.15 Seizures Seizures occurred in 0.2% (4/2547) of olanzapine and fluoxetine capsule-treated patients during open-label clinical studies. No seizures occurred in the controlled olanzapine and fluoxetine capsule studies. Seizures have also been reported with both olanzapine and fluoxetine monotherapy. Olanzapine and fluoxetine capsules 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. Olanzapine and fluoxetine capsules are not approved for the treatment of patients with Alzheimer’s disease. Conditions that lower the seizure threshold may be more prevalent in a population of ≥65 years of age. 5.16 Abnormal Bleeding SNRIs and SSRIs, including fluoxetine, may increase the risk of bleeding reactions. Concomitant use of aspirin, non-steroidal anti-inflammatory drugs, warfarin, and other anti-coagulants may add to this risk. Case reports and epidemiological studies (case-control and cohort design) have demonstrated an association between use of drugs that interfere with serotonin reuptake and the occurrence of gastrointestinal bleeding. Bleeding reactions related to SNRIs and SSRIs use have ranged from ecchymoses, hematomas, epistaxis, and petechiae to life-threatening hemorrhages. Patients should be cautioned about the risk of bleeding associated with the concomitant use of olanzapine and fluoxetine capsules and NSAIDs, aspirin, or other drugs that affect coagulation [ see Drug Interactions ( 7.4 ) and Patient Counseling Information ( 17.13 ) ]. 5.17 Hyponatremia Hyponatremia has been reported during treatment with SNRIs and SSRIs, including fluoxetine and olanzapine and fluoxetine capsules. In many cases, this hyponatremia appears to be the result of the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Cases with serum sodium lower than 110 mmol/L have been reported and appeared to be reversible when [ see Use in Specific Populations ( 8.5 ) ] olanzapine and fluoxetine capsules were discontinued. Elderly patients may be at greater risk of developing hyponatremia with SNRIs and SSRIs. Also, patients taking diuretics or who are otherwise volume depleted may be at greater risk. Discontinuation of olanzapine and fluoxetine capsules should be considered in patients with symptomatic hyponatremia and appropriate medical intervention should be instituted. Signs and symptoms of hyponatremia include headache, difficulty concentrating, memory impairment, confusion, weakness, and unsteadiness, which may lead to falls. More severe and/or acute cases have been associated with hallucination, syncope, seizure, coma, respiratory arrest, and death [ see Patient Counseling Information ( 17.14 ) ]. 5.18 Potential for Cognitive and Motor Impairment Olanzapine and fluoxetine capsules have 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 olanzapine and fluoxetine capsule therapy does not affect them adversely [ see Patient Counseling Information ( 17.15 ) ]. Adults — Sedation-related adverse reactions were commonly reported with olanzapine and fluoxetine capsule treatment occurring at an incidence of 26.6% in olanzapine and fluoxetine capsule-treated patients compared with 10.9% in placebo-treated patients. Sedation-related adverse reactions (sedation, somnolence, hypersomnia, and lethargy) led to discontinuation in 2% (15/771) of patients in the controlled clinical studies. Children and Adolescents — In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for the treatment of bipolar I depression in patients 10 to 17 years of age, somnolence-related adverse events were commonly reported with olanzapine and fluoxetine capsule treatment occurring at an incidence of 23.5% in olanzapine and fluoxetine capsule-treated patients compared with 2.4% in placebo-treated patients. Somnolence-related adverse events led to discontinuation in 1.2% (2/170) of patients. 5.19 Body Temperature Dysregulation Disruption of the body’s ability to reduce core body temperature has been attributed to antipsychotic drugs. Appropriate care is advised when prescribing olanzapine and fluoxetine capsules 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) [ see Patient Counseling Information ( 17.16 ) ]. 5.20 QT Prolongation Post-marketing cases of QT interval prolongation and ventricular arrhythmia including Torsade de Pointes have been reported in patients treated with fluoxetine. Olanzapine and fluoxetine capsules should be used with caution in patients with congenital long QT syndrome; a previous history of QT prolongation; a family history of long QT syndrome or sudden cardiac death; and other conditions that predispose to QT prolongation and ventricular arrhythmia. Such conditions include concomitant use of drugs that prolong the QT interval; hypokalemia or hypomagnesemia; recent myocardial infarction, uncompensated heart failure, bradyarrhythmias, and other significant arrhythmias; and conditions that predispose to increased fluoxetine exposure (overdose, hepatic impairment, use of CYP2D6 inhibitors, CYP2D6 poor metabolizer status, or use of other highly protein-bound drugs). Fluoxetine is primarily metabolized by CYP2D6 [ see Contraindications ( 4.2 ), Adverse Reactions ( 6 ), Drug Interactions ( 7.7 , 7.8 ), Overdose ( 10.1 ), and Clinical Pharmacology ( 12.3 ) ]. Pimozide and thioridazine are contraindicated for use with olanzapine and fluoxetine capsules. Avoid the concomitant use of drugs known to prolong the QT interval. These include specific antipsychotics (e.g., ziprasidone, iloperidone, chlorpromazine, mesoridazine, droperidol); specific antibiotics (e.g., erythromycin, gatifloxacin, moxifloxacin, sparfloxacin); Class 1A antiarrhythmic medications (e.g., quinidine, procainamide); Class III antiarrhythmics (e.g., amiodarone, sotalol); and others (e.g., pentamidine, levomethadyl acetate, methadone, halofantrine, mefloquine, dolasetron mesylate, probucol or tacrolimus) [ see Drug Interactions ( 7.7 , 7.8 ) and Clinical Pharmacology ( 12.3 ) ]. Consider ECG assessment and periodic ECG monitoring if initiating treatment with olanzapine and fluoxetine capsules in patients with risk factors for QT prolongation and ventricular arrhythmia. Consider discontinuing olanzapine and fluoxetine capsules and obtaining a cardiac evaluation if patients develop signs or symptoms consistent with ventricular arrhythmia. In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for the treatment of bipolar I depression in patients 10 to 17 years of age, there was a statistically significant difference in QT c interval for patients treated with olanzapine and fluoxetine capsules compared with patients on placebo: mean change in QT c F (Fridericia correction factor) from baseline to endpoint in patients treated with olanzapine and fluoxetine capsules was 8.2 msec (95% CI 6.2, 10.2). No patient developed QT c increases ≥60 msec or QT c ≥480 msec. Clinicians should use olanzapine and fluoxetine capsules with caution in those children or adolescents who are known to be particularly at risk for QT prolongation [ see Adverse Reactions ( 6.2 ) ]. 5.21 Antichlolinergic (antimuscarinic) Effects The following precautions for the individual components may be applicable to olanzapine and fluoxetine capsules. Olanzapine exhibits in vitro muscarinic receptor affinity. In premarketing clinical studies, olanzapine and fluoxetine capsules were associated with constipation, dry mouth, and tachycardia, all adverse reactions possibly related to cholinergic antagonism. Such adverse reactions were not often the basis for study discontinuations; olanzapine and fluoxetine capsules should be used with caution in patients with a current diagnosis or prior history of urinary retention, clinically significant 5.22 Hyperprolactinemia As with other drugs that antagonize dopamine D receptors, olanzapine and fluoxetine capsules elevate prolactin levels, and the elevation persists during administration. Hyperprolactinemia may suppress hypothalamic GnRH, resulting in reduced pituitary gonadotropin secretion. This, in turn, may inhibit reproductive function by impairing gonadal steroidogenesis in both female and male patients. Galactorrhea, amenorrhea, gynecomastia, and erectile dysfunction have been reported in patients receiving prolactin-elevating compounds. Long-standing hyperprolactinemia when associated with hypogonadism may lead to decreased bone density in both female and male subjects. As with other drugs that antagonize dopamine D 2 receptors, olanzapine and fluoxetine capsules elevate prolactin levels, and the elevation persists during administration. Hyperprolactinemia may suppress hypothalamic GnRH, resulting in reduced pituitary gonadotropin secretion. This, in turn, may inhibit reproductive function by impairing gonadal steroidogenesis in both female and male patients. Galactorrhea, amenorrhea, gynecomastia, and erectile dysfunction have been reported in patients receiving prolactin-elevating compounds. Long-standing hyperprolactinemia when associated with hypogonadism may lead to decreased bone density in both female and male subjects. Tissue culture experiments indicate that approximately one-third of human breast cancers are prolactin dependent , a factor of potential importance if the prescription of these drugs is contemplated in a patient with previously detected breast cancer. As is common with compounds that increase prolactin release, an increase in mammary gland neoplasia was observed in the olanzapine carcinogenicity studies conducted in mice and rats [ ]. Neither clinical studies nor epidemiologic studies conducted to date 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 at this time. 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. As is common with compounds that increase prolactin release, an increase in mammary gland neoplasia was observed in the olanzapine carcinogenicity studies conducted in mice and rats [ see Nonclinical Toxicology ( 13.1 ) ]. Neither clinical studies nor epidemiologic studies conducted to date 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 at this time. — In controlled clinical studies of olanzapine and fluoxetine capsules (up to 12 weeks), changes from normal to high in prolactin concentrations were observed in 28% of adults treated with olanzapine and fluoxetine capsules as compared to 5% of placebo-treated patients. The elevations persisted throughout administration of olanzapine and fluoxetine capsules. In a pooled analysis from clinical studies including 2929 adults treated with olanzapine and fluoxetine capsules, potentially associated clinical manifestations included menstrual-related events (1% [20/1946] of females), sexual function-related events (7% [192/2929] of females and males), and breast-related events (0.8% [16/1946] of females, 0.2% [2/983] of males). Adults — In controlled clinical studies of olanzapine and fluoxetine capsules (up to 12 weeks), changes from normal to high in prolactin concentrations were observed in 28% of adults treated with olanzapine and fluoxetine capsules as compared to 5% of placebo-treated patients. The elevations persisted throughout administration of olanzapine and fluoxetine capsules. In a pooled analysis from clinical studies including 2929 adults treated with olanzapine and fluoxetine capsules, potentially associated clinical manifestations included menstrual-related events 1 (1% [20/1946] of females), sexual function-related events 2 (7% [192/2929] of females and males), and breast-related events 3 (0.8% [16/1946] of females, 0.2% [2/983] of males). — In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for the treatment of bipolar I depression in patients 10 to 17 years of age, olanzapine and fluoxetine capsules were associated with a statistically significant greater mean change from baseline in prolactin levels compared to placebo (8.7 mcg/L vs 0.7 mcg/L, respectively). Although prolactin concentrations were very commonly (>10%) elevated above normal in both the olanzapine and fluoxetine capsules and placebo groups, more than twice as many olanzapine and fluoxetine capsule-treated patients were seen with these elevations compared to placebo-treated patients. Five patients experienced an adverse event potentially associated with elevated prolactin; these events included dysmenorrhoea, galactorrhoea, and ovulation disorder. Children and Adolescents — In a single, 8 week, randomized, placebo-controlled clinical trial investigating olanzapine and fluoxetine capsules for the treatment of bipolar I depression in patients 10 to 17 years of age, olanzapine and fluoxetine capsules were associated with a statistically significant greater mean change from baseline in prolactin levels compared to placebo (8.7 mcg/L vs 0.7 mcg/L, respectively). Although prolactin concentrations were very commonly (>10%) elevated above normal in both the olanzapine and fluoxetine capsules and placebo groups, more than twice as many olanzapine and fluoxetine capsule-treated patients were seen with these elevations compared to placebo-treated patients. Five patients experienced an adverse event potentially associated with elevated prolactin; these events included dysmenorrhoea, galactorrhoea, and ovulation disorder. The magnitude and frequency of change in prolactin in children and adolescents was larger than observed in adult patients treated with olanzapine and fluoxetine capsules, but was similar to that observed in adolescents treated with olanzapine monotherapy.The magnitude and frequency of change in prolactin in children and adolescents was larger than observed in adult patients treated with olanzapine and fluoxetine capsules, but was similar to that observed in adolescents treated with olanzapine monotherapy. Olanzapine Monotherapy In placebo-controlled olanzapine clinical studies (up to 12 weeks), changes from normal to high in prolactin concentrations were observed in 30% of adults treated with olanzapine as compared to 10.5% of adults treated with placebo. In a pooled analysis from clinical studies including 8136 adults treated with olanzapine, potentially associated clinical manifestations included menstrual-related events (2% [49/3240] of females), sexual function-related events (2% [150/8136] of females and males), and breast-related events (0.7% [23/3240] of females, 0.2% [9/4896] of males). In placebo-controlled olanzapine clinical studies (up to 12 weeks), changes from normal to high in prolactin concentrations were observed in 30% of adults treated with olanzapine as compared to 10.5% of adults treated with placebo. In a pooled analysis from clinical studies including 8136 adults treated with olanzapine, potentially associated clinical manifestations included menstrual-related events 1 (2% [49/3240] of females), sexual function-related events 2 (2% [150/8136] of females and males), and breast-related events 3 (0.7% [23/3240] of females, 0.2% [9/4896] of males). In placebo-controlled olanzapine monotherapy studies in adolescent patients (up to 6 weeks) with schizophrenia or bipolar I disorder (manic or mixed episodes), changes from normal to high in prolactin concentrations were observed in 47% of olanzapine-treated patients compared to 7% of placebo-treated patients. In a pooled analysis from clinical trials including 454 adolescents treated with olanzapine, potentially associated clinical manifestations included menstrual-related events (1% [2/168] of females), sexual function-related events (0.7% [3/454] of females and males), and breast-related events (2% [3/168] of females, 2% [7/286] of males) [ ]. In placebo-controlled olanzapine monotherapy studies in adolescent patients (up to 6 weeks) with schizophrenia or bipolar I disorder (manic or mixed episodes), changes from normal to high in prolactin concentrations were observed in 47% of olanzapine-treated patients compared to 7% of placebo-treated patients. In a pooled analysis from clinical trials including 454 adolescents treated with olanzapine, potentially associated clinical manifestations included menstrual-related events 1 (1% [2/168] of females), sexual function-related events 2 (0.7% [3/454] of females and males), and breast-related events 3 (2% [3/168] of females, 2% [7/286] of males) [ see Use in Specific Populations ( 8.4 ) ]. Based on a search of the following terms: amenorrhea, hypomenorrhea, menstruation delayed, and oligomenorrhea. 1 Based on a search of the following terms: amenorrhea, hypomenorrhea, menstruation delayed, and oligomenorrhea. Based on a search of the following terms: anorgasmia, delayed ejaculation, erectile dysfunction, decreased libido, loss of libido, abnormal orgasm, and sexual dysfunction. 2 Based on a search of the following terms: anorgasmia, delayed ejaculation, erectile dysfunction, decreased libido, loss of libido, abnormal orgasm, and sexual dysfunction. Based on a search of the following terms: breast discharge, enlargement or swelling, galactorrhea, gynecomastia, and lactation disorder. 3 Based on a search of the following terms: breast discharge, enlargement or swelling, galactorrhea, gynecomastia, and lactation disorder. Dose group differences with respect to prolactin elevation have been observed. In a single 8 week randomized, double-blind, fixed-dose study comparing 10 (n=199), 20 (n=200) and 40 (n=200) mg/day of oral olanzapine in adult patients with schizophrenia or schizoaffective disorder, incidence of prolactin elevation >24.2 ng/mL (female) or >18.77 ng/mL (male) at any time during the trial (10 mg/day: 31.2%; 20 mg/day: 42.7%; 40 mg/day: 61.1%) indicated significant differences between 10 vs 40 mg/day and 20 vs 40 mg/day Dose group differences with respect to prolactin elevation have been observed. In a single 8 week randomized, double-blind, fixed-dose study comparing 10 (n=199), 20 (n=200) and 40 (n=200) mg/day of oral olanzapine in adult patients with schizophrenia or schizoaffective disorder, incidence of prolactin elevation >24.2 ng/mL (female) or >18.77 ng/mL (male) at any time during the trial (10 mg/day: 31.2%; 20 mg/day: 42.7%; 40 mg/day: 61.1%) indicated significant differences between 10 vs 40 mg/day and 20 vs 40 mg/day . 5.23 Concomitant Use of Olanzapine and Fluoxetine Products Olanzapine and fluoxetine capsules contain the same active ingredients that are in Zyprexa ® , Zyprexa ® Zydis ® , Zyprexa ® Relprevv TM (olanzapine), and in Prozac ® , Prozac ® Weekly ™ , and Sarafem ® (fluoxetine HCl). Caution should be exercised when prescribing these medications concomitantly with olanzapine and fluoxetine capsules [ see Overdosage ( 10 ) ]. 5.24 Long Elimination Half-Life of Fluoxetine Because of the long elimination half-lives of fluoxetine and its major active metabolite, changes in dose will not be fully reflected in plasma for several weeks, affecting both strategies for titration to final dose and withdrawal from treatment. This is of potential consequence when drug discontinuation is required or when drugs are prescribed that might interact with fluoxetine and norfluoxetine following the discontinuation of fluoxetine [ see Clinical Pharmacology ( 12.3 ) ]. 5.25 Discontinuation Adverse Reactions During marketing of fluoxetine, a component of olanzapine and fluoxetine capsules, SNRIs, and SSRIs, there have been spontaneous reports of adverse reactions occurring upon discontinuation of these drugs, particularly when abrupt, including the following: dysphoric mood, irritability, agitation, dizziness, sensory disturbances (e.g., paresthesias such as electric shock sensations), anxiety, confusion, headache, lethargy, emotional lability, insomnia, and hypomania. While these reactions are generally self-limiting, there have been reports of serious discontinuation symptoms. Patients should be monitored for these symptoms when discontinuing treatment with fluoxetine. A gradual reduction in the dose rather than abrupt cessation is recommended whenever possible. If intolerable symptoms occur following a decrease in the dose or upon discontinuation of treatment, then resuming the previously prescribed dose may be considered. Subsequently, the physician may continue decreasing the dose but at a more gradual rate. Plasma fluoxetine and norfluoxetine concentration decrease gradually at the conclusion of therapy, which may minimize the risk of discontinuation symptoms with this drug [ see Dosage and Administration ( 2.4 ) and Patient Counseling Information ( 17.18 ) ]. 5.26 Sexual Dysfunction Use of SSRIs, including fluoxetine a component of olanzapine and fluoxetine capsules, may cause symptoms of sexual dysfunction [see Adverse Reactions (6.1)]. In male patients, olanzapine and fluoxetine capsules use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction. In female patients, olanzapine and fluoxetine capsules use may result in decreased libido and delayed or absent orgasm. It is important for prescribers to inquire about sexual function prior to initiation of olanzapine and fluoxetine capsules and to inquire specifically about changes in sexual function during treatment, because sexual function may not be spontaneously reported. When evaluating changes in sexual function, obtaining a detailed history (including timing of symptom onset) is important because sexual symptoms may have other causes, including the underlying psychiatric disorder. Discuss potential management strategies to support patients in making informed decisions about treatment. 5.26 Sexual Dysfunction Use of SSRIs, including fluoxetine a component of olanzapine and fluoxetine capsules, may cause symptoms of sexual dysfunction [see Adverse Reactions (6.1)]. In male patients, olanzapine and fluoxetine capsules use may result in ejaculatory delay or failure, decreased libido, and erectile dysfunction. In female patients, olanzapine and fluoxetine capsules use may result in decreased libido and delayed or absent orgasm. It is important for prescribers to inquire about sexual function prior to initiation of olanzapine and fluoxetine capsules and to inquire specifically about changes in sexual function during treatment, because sexual function may not be spontaneously reported. When evaluating changes in sexual function, obtaining a detailed history (including timing of symptom onset) is important because sexual symptoms may have other causes, including the underlying psychiatric disorder. Discuss potential management strategies to support patients in making informed decisions about treatment.