Q: I have a 17 y/o girl that refuses to take olanzapine because at the John Hopkins clinic she was given a list of medications that she should avoid because they can increase QTC. She has a mitral valve prolapse, asymptomatic but causes a heart murmur. I don’t have any negative experience with olanzapine and QTC, but it is listed in the package insert as a moderate possibility. In all the years after that first encounter with this medication my only concern has been the metabolic syndrome. I Rx 5 mg of olanzapine and d/c the previous medications.
She came on mirtazapine 015 mg HS, lorazepam 0.5 QID and cyproheptadyne 4 mg HS. Still, it takes her about 3 hours to fall sleep (“I have problem falling sleep all my life”). Her mood is elevated and she has a grandiose demeanor. Also she has strong OCD traits.
PL: The best approach is to treat causes not effects. Insomnia is a symptom of a manic state, as you’ve described it. So any anti-manic drug should help her insomnia, because it will get at the cause, which is the manic state; it need not be sedating symptomatically as well. All dopamine blockers can increase QTc, but the worst among the newer ones are ziprasidone and iloperidone. Lurasidone is chemically derived from ziprasidone and thus should be avoided. There is some risk with all other agents though. In the PL view, olanzapine should be avoided in general due to its severe metabolic syndrome, which can be acute and immediate, with cases of diabetic ketoacidosis. Quetiapine also causes metabolic syndrome. Risperidone does not, and would be a fine choice here. Asenapine is the most sedating reasonable option which is mostly purely antidopaminergic, which could be considered after risperidone. Dopaminergic or monoaminergic agonists are less effective for manic states, i.e., abilify, ziprasidone, lurasidone, cariprazine.