Letters to the Editor
Treatment Noncompliance With Orally Disintegrating Olanzapine Tablets
Dear Editor:
Recently, Chue and colleagues suggested that new formulations of antipsychotics that are fast-dissolving in the mouth, such as orally disintegrating olanzapine tablets, are welcome. They are seemingly impossible to “cheek” and may improve medication adherence (1). In selected patients, this is true. However, such novel drug formulations are no panacea against noncompliance, which was exemplified by a patient who managed to be noncompliant with fast-dissolving olanzapine tablets (2).
Case Report
Ms A was a 52-year-old woman with chronic schizophrenia and tardive dyskinesia and a long history of noncompliance with antipsychotics, resulting in a cyclical pattern of hospitalizations that alternated with homelessness. Untreated, she was hostile, disorganized, and dishevelled. With antipsychotic treatment, she was pleasant, was able to follow ward routines, and took pride in her appearance, with great concern for potential weight gain. She never regarded herself as ill and always denied the need for medication.
After being involuntarily hospitalized, a 6-month clozapine trial failed, because the patient remained adversarial to taking medications. Despite great staff effort, she decompensated twice in hospital, owing to noncompliance (corroborated by plasma levels).
After she agreed to try out this newly formulated medicine, an olanzapine wafer trial was initiated. Although she was apparently compliant, no clinical improvement occurred after several weeks of olanzapine wafers at a dosage of 20 mg daily. A steady-state olanzapine plasma level was unexpectedly low (8.5 ng/mL). Finally, a nurse observed the following “cheeking” technique: the patient put the Zydis wafer up behind her front teeth near the gum line. It appeared that she kept her mouth dry to allow the wafer to stick in place. In this way, she managed to produce the wafer largely intact, minutes after it was administered. After this experience, she was started on haloperidol decanoate.
Discussion
Patients who appear treatment-resistant could be noncompliant with antipsychotics. This patient had several risk factors for noncompliance: lack of insight into her illness or of medication benefit, a long history of noncompliance, and severe side effects to antipsychotics (3). We nevertheless did not consider noncompliance as a likely possibility, owing to the supervised medication dispensation and a prima facie “foolproof” medication administration method. In hindsight, this was a mistake. Still, patients must be observed closely to ensure that the wafer disintegrates completely and is swallowed, because buccal absorption is negligible.
Thus, this case serves as a reminder that fast-dissolving oral medication is no substitute for parenteral medication.
References
1. Chue P, Jones B, Taylor CC, Dickson R. Dissolution profile, tolerability, and acceptability of the orally disintegrating olanzapine tablet in patients with schizophrenia. Can J Psychiatry 2002;47:771–4.
2. Seager H. Drug-delivery products and the Zydis fast-dissolving dosage form. J Pharm Pharmacol 1998;50:375–82.
3. Fenton WS, Blyler CR, Heinssen RK. Determinants of medication compliance in schizophrenia: empirical and clinical findings. Schizophr Bull 1997;23:637–51.
Oliver Freudenreich, MD
Boston, Massachusetts
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