Subcutaneous Olanzapine at the End of Life in a Patient with Schizophrenia and Dysphagia

Currently, there is a paucity of evidence to guide the management of antipsychotic therapy at the end of life for patients with schizophrenia. A 51-year-old female with a diagnosis of palliative squamous cell carcinoma of the tonsils was admitted to her local hospice for end-of-life care. She had a history of treatment-resistant schizophrenia, which was ordinarily managed with oral clozapine and aripiprazole. Owing to a deteriorating swallow and the inappropriateness of other enteral administration routes for this patient however, it became necessary to consider alternative means by which to give essential antipsychotic medicine. A subcutaneous infusion of olanzapine was chosen as the most viable solution. During the course of the admission, her schizophrenia began to relapse with the onset of positive psychotic symptoms (paranoia and hallucinations). This was posited as likely due to interruption of her regular oral antipsychotic medication combined with insufficient olanzapine dosing. The olanzapine dose was thus subsequently titrated over the course of a week with close monitoring, and her psychotic symptoms abated. Owing to a protracted dying phase, the patient remained on subcutaneous olanzapine for a total of 56 days, which allowed for accurate assessment of her psychiatric symptoms and evaluation of therapeutic response. The findings of this case report suggest that subcutaneous olanzapine may be an appropriate alternative for patients who are unable to take their complex oral antipsychotic regimens through enteral routes at the end of life.