i E
`
`fficacy of Olanzapine in Combination With
`Valproate or Lithium in the Treatment of Mania
`in Patients Partially Nonresponsive
`to Valproate or Lithium Monotherapy
`
`Mauricio Tohen, MD, DrPH; K. N. Roy Chengappa, MD; Trisha Suppes, MD, PhD; Carlos A. Zarate, Jr, MD;
`Joseph R. Calabrese, MD; Charles L. Bowden, MD; Gary S. Sachs, MD; DavidJ. Kupfer, MD;
`Robert W. Baker, MD; Richard C. Risser, MSc; Elisabeth L. Keeter, RN, MSN; Peter D. Feldman, PhD;
`Gary D.Tollefson, MD, PhD; Alan Breier, MD
`
`Background: A 6-week double-blind, randomized,pla-
`cebo-controlled trial was conducted to determinetheef-
`ficacy of combined therapy with olanzapine and either
`valproate or lithium compared with valproate or lithium
`alone in treating acute manic or mixed bipolar episodes.
`
`Methods: The primary objective wasto evaluate the ef-
`ficacy of olanzapine (5-20 mg/d) vs placebo when added
`to ongoing mood-stabilizer therapy as measured byre-
`ductions in Young Mania Rating Scale (YMRS) scores.
`Patients with bipolar disorder (n=344), manic or mixed
`episode, who were inadequately responsive to more than
`2 weeks oflithium or valproate therapy, were random-
`ized to receive cotherapy (olanzapine + mood-
`stabilizer) or monotherapy (placebo + mood-stabilizer).
`
`proved 21-item Hamilton Depression Rating Scale (HAMD-
`21) total scores significantly more than monotherapy (4.98
`vs 0.89 points; P<.001). In patients with mixed-episodes
`with moderate to severe depressive symptoms (DSM-IV
`mixed episode; HAMD-21 score of = 20 atbaseline), olan-
`zapine cotherapy improved HAMD-21 scores by 10.31
`points comparedwith 1.57 for monotherapy (P<.001). Ex-
`trapyramidal symptoms (Simpson-Angus Scale, Barnes Aka-
`thisia Scale, Abnormal Involuntary MovementScale) were
`not significantly changed from baselineto end pointin ei-
`ther treatment group. Treatment-emergent symptoms that
`weresignificantly higher for the olanzapine cotherapy group
`included somnolence, dry mouth, weight gain, increased
`appetite, tremor, and slurred speech.
`
`Results: Olanzapine cotherapy improved patients’: YMRS
`total scores significantly more than monotherapy (-13.11
`vs -9.10; P=.003). Clinical response rates (=50% improve-
`ment on YMRS)weresignificantly higher with cotherapy
`(67.7% vs 44.7%; P<.001). Olanzapine cotherapy im-
`Arch Gen Psychiatry. 2002;59:62-69
`
`HE EXPERT Consensus
`Guidelines Series, pub-
`lished in the year 2000,
`recommends lithium and
`valproate as first-line treat-
`ments for bipolar mania.! However, up to
`40% of patients respond poorly to mono-
`therapywith either treatment.” When mono-
`therapy fails, the guidelines recommend
`combination therapies. A numberof au-
`thors haverecently reviewed theuseofsuch
`cotherapies for bipolar mania. Freeman and
`Stoll? concluded that the combination of
`lithium andvalproateis better tolerated and
`more efficacious in maintenance therapy
`than other combination treatments.
`Typical neuroleptics have been sug-
`gested to be superiorin efficacy to lithium
`monotherapy.* Conversely, the addition of
`a moodstabilizer to conventional antipsy-
`
`A list of the Principal
`Investigators appears in
`the box on page 69. Author
`affiliations appear in the
`acknowledgmentsection.
`Drs Tohen, Feldman, Tollefson,
`and Breier and MrRisser and
`MsKeeter are stockholders
`in Eli Lilly & Co.
`
`Conelusion: Compared with the use of valproate or
`lithium alone, the addition of olanzapine provided su-
`perior efficacy in the treatment of manic and mixedbi-
`polar episodes.
`
`chotic therapy seemssuperior to antipsy-
`chotic agents alone.® In supportofthis,
`Miller-Oerlinghausen etal° compared the
`efficacy of combined therapy with con-
`ventional antipsychotics and valproate vs
`valproate monotherapyin patients with bi-
`polaror schizoaffective disorder and found
`combination therapy to be superior to
`monotherapy.
`Olanzapine, an atypical antipsy-
`chotic, has been shown in 2 placebo-
`controlled studies to have acute antimanic
`effects.’® Moreover, a previous report has
`suggestedthat olanzapineis effective when
`used in combination with other psycho-
`tropic agents.’ The presentstudy was con-
`ductedto investigate the efficacy andsafety
`of combined therapy with olanzapine and
`either valproate or lithium compared with
`valproate orlithium monotherapy.
`
`(REPRINTED) ARCH GEN PSYCHIATRY/VOL 19, JAN 2002
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`SUBJECTS AND METHODS
`
`ASSESSMENTS
`
`SUBJECTS
`
`All patients were diagnosedas havingbipolar disorder, manic
`or mixed episode, with or without psychotic features, us-
`ing the Structured Clinical Interview for the DSM-IV'°
`(SCID)."' Patients had to have at least 2 previous de-
`pressed, manic, or mixed episodesas well as a Young Ma-
`nia Rating Scale’? (YMRS)total score of 16 orgreateratvisit
`1 and visit 2 (2-7 dayslater). Patients were required to have
`had a documentedtrial of treatment, with a therapeutic
`bloodlevel oflithium (0.6-1.2 mmol/L) orvalproate (50-
`125 pg/mL),for at least 2 weeks immediately priorto visit
`1. Patients were included onlyif they showed inadequate
`response to monotherapy (YMRS total score = 16). Prior
`to participation,all patients signed an informed consent
`documentapprovedbytheir study site’s institutionalre-
`view board.
`
`STUDY DESIGN
`
`Participants in the studyinitially entered a 2- to 7-day screen-
`ing and washoutperiod (study period 1) during which all
`concomitant medications other thanlithium or valproate
`were discontinued. Patients already receiving valproate or
`lithium continuedto do so throughoutthestudy. Patients
`receiving other forms of treatmentstarted receiving either
`lithium orvalproateat investigatordiscretion for the 2 weeks
`immediately priorto visit 1. Plasma levels of the medica-
`tions were documentedto be within the therapeutic ranges.
`Only patients scoring greater than or equal to 16 on the
`YMRS were randomized to receive concurrent treatment
`combined with either olanzapine or placebo (study pe-
`riod 2).
`Study period 2 consisted of a 6-week acute, double-
`blind phase, during whichlevels oflithium or valproate were
`maintained within the therapeutic range. Patients were as-
`sessed weekly. Patients were randomized2:1 to receiveei-
`ther olanzapine(flexible dose range of 5, 10, 15, or 20 mg/d)
`added to valproateor lithium or placebo addedto valpro-
`ate or lithium. Olanzapine therapy was initiated at 10 mg/d.
`To maintain blinding, treatmenttook the form of two 5-mg
`capsules (either olanzapineor placebo), titrated up in in-
`crements of 1 capsule or down by any numberofdecre-
`ments at investigator discretion as indicated by each pa-
`tient’s tolerance. Patients unableto tolerate the minimum
`dose were discontinued. Patients were permitted adjunc-
`tive use of benzodiazepine (=2 mg/d of lorazepam equiva-
`lents) for no more than 14 days cumulatively. Anticholin-
`ergic therapy (benztropine mesylate, =2 mg/d) was
`permitted throughoutthe study for treatmentof extrapy-
`ramidal symptoms butnot for prophylaxis. Aside from study
`drugs, benzodiazepines, and anticholinergics, no other drugs
`were permitted during the study.
`
`Patient assessments were conducted by mentalhealth care
`professionals, including psychiatrists, psychologists, nurses,
`and other mental health caregivers with a clinical degree
`orcertification. Raters were trained in the use of the SCID
`and symptom-rating scales before study initiation. To en-
`sure high interrater reliability, investigators were re-
`quired to achievea reliability coefficient of 0.75 or greater.
`The primary measureofefficacy to assess severity of manic
`symptomswas the mean change from baseline to end point
`in the YMRS total score. Secondary measures included the
`21-item Hamilton Depression Rating Scale!? (HAMD-21);
`the Positive and Negative SyndromeScale'*; and the Clini-
`cal Global Impressions Severity of Bipolar Disorder scale!*
`(CGI-BP)total scores, and mania and depression subscale
`scores. Clinical responses on the YMRS and HAMD-21 were
`defined a priori as an improvement of 50% orgreater.Clini-
`cal remission (euthymia) was defined a priori as achieve-
`ment of a YMRStotal scoreof less than or equal to 12. A
`subsample ofpatients with moderate to severe depressive
`symptoms was defined by a current mixed episode and a
`HAMD-21 total score of 20 or greater at baseline. Second-
`ary assessments,also defineda priori, included analyses of
`treatmentdifferences following stratification by the cur-
`rent course of illness, the presence or absence of psy-
`chotic features, and the useof lithium or valproate.
`Scales for the assessmentof neurologic adverse events
`included the Simpson-AngusScale,'? the Barnes Akathisia
`Scale,’© and the Abnormal Involuntary MovementScale."*
`Assessmentofvital signs, weight, and clinical laboratory
`analytes (includingprolactin, nonfasting glucose, and elec-
`trolyte levels and hematologic analysis) was performedat
`eachvisit. Serum concentrations of mood stabilizers were
`collected at every visit.
`
`STATISTICAL ANALYSES
`
`Data were analyzed on an intent-to-treat basis,'’ included
`all patients who met the entry criteria (including inad-
`equate responsiveness to the minimum 2-weekpriortreat-
`mentwith lithium orvalproate), and provided both a base-
`line and atleast 1 postbaseline data measurement. Total
`scores from rating scales were derived from the individual
`items; if any item was missing,thetotal score was treated
`as missing. All tests were 2-sided, with an o level of .05.
`Analysis of variance (ANOVA) models were used to evalu-
`ate continuous data, including terms for treatment, inves-
`tigator, and treatment-investigator interaction. Thelinear
`modelfor this analysis included terms for baseline, treat-
`ment, investigator, treatment-investigatorinteraction,visit,
`and treatment-visit interaction. The Fisher exact test was
`usedfor categorical analyses, including laboratory values,
`vital signs, and treatment-emergent adverse events. Data
`are given as mean (SD) unless otherwiseindicated.
`
`PATIENT CHARACTERISTICS AND DISPOSITION
`
`A total of 501 patients entered the screening phase and
`344 patients were randomized andenrolled (33 UScen-
`ters, 5 Canadian), with a mean enrollmentof 9 patients
`
`persite. Patients were recruited from both academic and
`nonacademicsites from existing clinical patient popu-
`lations seeking treatmentatthosesites. Of the 344 ran-
`domized patients, 322 came from outpatient centers. The
`other 20 (cotherapy, n=16; monotherapy, n=4) came
`from inpatientsettings. Patients wereinitially screened
`on thebasis of face-to-face interviews, medical record re-
`
`(REPRINTED) ARCH GEN PSYCHIATRY/VOL59, JAN 2002
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`73 (64.0)
`
`Table 1. Patient Char icteristics
`
`Characteristic
`
`Age, mean + SD, y
`
`Male, No. (%)
`
`White, No. (%)
`
`Current course, No. (%)
`Manic
`Mixed
`
`Manic
`Mixed
`
`Manic
`Mixed
`Without psychotic features, No. (%)t
`
`Cotherapeutic agent, No. (%)
`Lithium
`Valproate
`
`P Value*
`9
`2
`25
`05
`34
`08
`75
`79
`99
`21
`
`03
`
`MoodStabilizer
`
`Lithium
`Valproate
`
`Lithium
`Valproate
`
`Lithium
`Valproate
`
`Lithium
`
`Valproate
`
`Lithium
`Valproate
`
`Olanzapine Cotherapy
`(a = 229)
`40.7 £11.2
`40.8 + 12.4
`40.7 + 10.7
`101 (44.1)
`41 (54.0)
`60 (39.2)
`196 (85.6)
`65 (85.5)
`131 (85.6)
`
`104 (45.4)
`125 (54.6)
`
`38 (50.0)
`38 (50.0)
`
`87 (56.9)
`66 (43.1)
`154 (67.3)
`54 (71.1)
`100 (65.4)
`
`76 (33.2)
`153 (66.8)
`
`Monotherapy
`(n = 115)
`40.4 + 10.8
`43.44 11.0
`38.9 + 10.5
`64 (55.6)
`26 (63.4)
`38 (52.1)
`97 (84.4)
`34 (82.9)
`63 (86.3)
`
`61 (53.0)
`54 (47.0)
`
`12 (29.3)
`29 (70.7)
`
`42 (57.5)
`31 (42.5)
`76 (66.1)
`28 (68.3)
`48 (65.8)
`
`41 (36.0)
`
`*Treatment difference, olanzapine cotherapy vs monotherapy; derived from analysis of variance for age and from the Fisher exact test otherwise.
`}Based on n = 114 for monotherapy.
`
`views, and information obtained from family members
`and referring clinicians. Reasonsfor lack of enrollment
`included entry criteria not met (86 patients, including
`24 failing to meet the YMRS totalscorecriterion of =16);
`patient decision orloss to follow-up during the screen-
`ing phase (58); investigator decision (8); protocol vio-
`lation (4); and a single death that occurred before
`completion of screening or exposureto the study drug.
`Ultimately, 229 patients were randomizedto receive
`olanzapine cotherapy and 115 to receive monotherapy
`(Table 1). One patient in the monotherapy groupre-
`ceived both valproate and lithium and accordingly was
`excluded from the subgroup analyses. The median du-
`ration of mood-stabilizer therapy prior to randomiza-
`tion was 67 days; 203 patients had a duration of therapy
`longer than 6 weeks. Onepatient in the monotherapy
`group and 9 in the cotherapy group had nopostbaseline
`measures and were excludedfromail efficacy analyses.
`The percentageof patients completing the study was
`roughly equal in the 2 treatment groups (cotherapy,
`69.9%; monotherapy, 71.3%). Significantly more pa-
`tients in the monotherapy group discontinuedtreat-
`ment dueto lack of efficacy (12.2% vs 3.1%; P=.002),
`whereas significantly more patients in the cotherapy group
`withdrew dueto adverse events (10.9% vs 1.7%; P=.002)
`(Table 2).
`Patient demographics andillness characteristics were
`notsignificantly different between the cotherapy and
`monotherapytreatment groupsoverall (Table 1). In the
`overall study group (n=344), the mean age was 40.6
`(11.1) years. One hundredsixty-five patients (48.0%) had
`mixed episodes at enrollment; the remainder had pure
`
`manic episodes. Overall baseline mean YMRS total scores
`for the olanzapine cotherapy (n=220) and mono-
`therapy (n=114) groups were 22.31 (5.39) and 22.67
`(5.15), respectively, and mean HAMD-21 scores were
`14.52 (8.46) and 13.54 (7.63), respectively (Table 3).
`Mean modal dose of olanzapine in the cotherapy
`group (n=224) was 10.4 (4.9) mg/d). Mean plasmalev-
`els of lithium among the cotherapy (n=74) and mono-
`therapy (n=41) patients were 0.76 (0.16) and 0.82 (0.19)
`(Fi as=4.26; P=.04) mEq/L,respectively, while mean
`plasmalevels of valproate for cotherapy (n=145) and
`monotherapy (n=73) were 63.6 (18.4) pg/mL and 74.7
`(18.6) pg/mL,respectively (Fy 1s8= 18.38; P<.001). Ben-
`zodiazepine use was notstatistically different between
`patients in the cotherapy (66/229 [28.8%]) and mono-
`therapy (39/115 [33.9%]) groups (P=.38).
`
`PRIMARY OUTCOMES
`
`Both groupsof patients improved during the course of
`treatment as indicated by the primary measure ofeffi-
`cacy, the YMRS total score (Table 3). However,the olan-
`zapine cotherapy group (n=220) showed a mean de-
`crease in YMRStotal score of 13.1 (8.53) points,
`corresponding to a 58.8% improvementfrom baseline
`comparedwith a decrease of9.10 (9.36) points F,276=9.08;
`P=.003) for the monotherapy group (n= 114), which cor-
`responded to an improvementof 40.1%.
`Itemwise analysis of the YMRS revealed that, com-
`pared with monotherapy,olanzapine cotherapy brought
`aboutsignificantly greater improvementat end point on
`the itemsofIrritability (cotherapy, -1.82 [2.09], n=220;
`
`(REPRINTED) ARCH GEN PSYCHIATRY/VOL59, JAN 2002
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`0
`
`fable 2. Patient Disposition*
`
`Characteristic
`
`Completed study, No.
`
`Reasonsfor discontinuation
`Adverse event
`
`Lackof efficacy
`
`Lost to follow-up
`
`Patient decision
`
`Criteria not met/compliance
`
`Sponsordecision
`
`Physician decision
`
`Satisfactory response
`
`Mood Stabilizer
`
`Olanzapine Cotherapy
`(n = 229)
`
`Monotherapy
`(n = 115)
`
`P Valuet
`
`Full sample
`Lithium
`Valproate
`
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`
`160 (69.9)
`58 (76.3)
`102 (66.7)
`
`25 (10.9)
`5 (6.6)
`20 (13.1)
`
`228)
`
`5 (3.3)
`5 (2.2)
`2 (2.6)
`3 (2.0)
`13 (5.7)
`3 (4.0)
`10 (6.5)
`12 (5.2)
`3 (4.0)
`9 (5.9)
`1 (0.4)
`0
`4 (07)
`5 (2.2)
`2 (2.6)
`3 (2.0)
`4 (0.4)
`1 (1.3)
`0
`
`82 (71.3)
`32 (78.1)
`50 (68.5)
`
`2(1.7)
`0
`2 (2.74)
`
`188)
`
`9 (12.3)
`3 (2.6)
`2 (4.9)
`1 (1.4)
`2(1.7)
`1 (2.4)
`1 (1.4)
`5 (4.3)
`1 (2.4)
`4 (5.5)
`1 (0.9)
`1 (2.4)
`0
`6 (5.2)
`0
`6 (8.2)
`0
`0
`
`*Data are given as number (percentage) uniess otherwise indicated.
`tTreatmentdifference, olanzapine cotherapy vs monotherapy; derived from the Fisher exacttest.
`
`monotherapy, -1.02 [2.37], n=114; Fy276=5.69; P=.02);
`Speech (cotherapy, -2.45 [2.03], n=220; monotherapy,
`-1.63 [2.53], n=114; Fi276=5.24; P=.02); Language/
`Thought Disorder (cotherapy, -0.94 [0.91], n=220,
`monotherapy,-0.72 [1.00], n=114; Fya76=5.34; P=.02);
`and Disruptive/Aggressive Behavior (cotherapy, -1.18
`[1.64], n=220; monotherapy, -0.46 [1.77], n=114;
`F, 276= 10.16; P=.002).
`Clinical response wasdefined a priori in the protocol
`as improvementof 50% orgreater from baselineto end point
`in the YMRS totalscore. Onthis basis, 149 (67.7%) of the
`220 patients in the olanzapine cotherapy group re-
`spondedto treatment compared with 51 (44.7%) of the 114
`patients in the monotherapy group (P<.001). In addi-
`tion, time to response wassignificantly shorter for co-
`therapy (P=.002, log rank test), with a median response
`time of 18 days for cotherapy vs 28 days for monotherapy.
`
`SECONDARY OUTCOMES
`
`Clinical remission was defined a priori in the protocol
`as achievementof a YMRS totalscore ofless than or equal
`to 12. On this basis, 173 (78.6%) of the 220 patients in
`the olanzapine cotherapy group demonstrated evidence
`of remission. In the monotherapy group, 75 (65.8%) of
`the 114 evaluated patients demonstrated evidenceofre-
`mission. This difference in remission rates wasalsosig-
`nificant (P=.01). Time to remission wassignificantly
`shorter in the cotherapy group (log rank test, P=.002),
`
`with a median remission time of 14 days for cotherapy
`vs 22 days for monotherapy.
`Compared with the patients in the monotherapy group,
`patients in the olanzapine cotherapy group showedsig-
`nificantly greater improvement on the HAMD-21at each
`time point throughout the study. By week 6, the co-
`therapy group (n=220) experienced a meanlast observa-
`tion carried forward decrease in HAMD-21 scores of 4.98
`(7.61) points,significantly greater (F,276= 18.05; P<.001)
`than the decrease of 0.89 (6.90) points in the mono-
`therapy group (n=114). An exploratory itemwise analy-
`sis showedsignificantly greater improvementin the di-
`mensions of depressed mood,feelings ofguilt, suicidality,
`early insomnia, anxiety-psychic, and paranoid symptoms.
`Analysis of end point HAMD-21scores conductedin
`the subsetof patients experiencing a mixed episode with
`moderate to severe depressive symptomsat baseline
`(HAMD-21 total score =20 at baseline) showed a de-
`crease of 10.31 (8.19) points for olanzapine cotherapy
`(n=51) compared with 1.57 (7.73) points (F,.79= 17.50;
`P<,001) for monotherapy (n=21). Within this subset,
`43.1% of patients in the cotherapy group showed =50%
`improvementofdepressive symptoms compared with 9.5%
`in the monotherapy group (P=.006).
`Other secondary measuresofefficacy included the
`Positive and Negative SyndromeScale (total; Positive,
`Negative, and Cognitive clusters; and Hostility sub-
`scores) and the CGI-BP (overall, Severity of Mania, and
`Severity of Depression). Olanzapine cotherapy brought
`
`(REPRINTED) ARCH GEN PSYCHIATRY/VOL 59, JAN 2002
`6
`4 oF 8
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`0.39
`
`Comparison
`
`F
`Statistict
`
`Effect
`Size
`
`P
`Valuet
`
`9.08
`3.10
`4.51
`18.05
`3.58
`14.77
`4.48
`0.24
`2.08
`2.94
`1.70
`0.10
`13.84
`0.46
`15.79
`8.78
`
`.
`;
`:
`.
`.
`.
`
`0.47
`0.42
`0.50
`0.58
`0.40
`0.65
`0.27
`0.20
`0.33
`0.26
`0.40
`0.20
`0.48
`0.36
`0.57
`0.42
`0.40
`0.42
`0.21
`0.01
`0.31
`0.39
`0.45
`
`Table 3. Summary of Efficacy Results, Baseline to End Point Changes*
`
`Olanzapine Cotherapy (n = 220)
`
`Monotherapy
`(n = 114)
`
`Measurement
`Scale
`
`YMRSTotal
`
`HAMD-21Total
`
`CGI-BP Overall
`
`CGI-BP Mania
`
`CGI-BP Depression
`
`PANSSTotal
`
`PANSSCognition
`
`PANSSHostility
`
`Mood
`Stabilizer
`
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Fult sample
`Lithium
`Valproate
`
`Baseline:
`mean (SD)
`22.31 (5.39)
`22.34 (5.26)
`22.29 (5.48)
`14.52 (8.46)
`14.26 (8.33)
`14.65 (8.55)
`4.10 (0.74)
`4.12 (0.78)
`4.10 (0.73)
`4.06(0.79)
`4.42 (0.72)
`4.03 (0.82)
`2.76 (1.40)
`2.59 (1.32)
`2.84 (1.43)
`62.10 (17.28)
`61.43 (15.85)
`62.45 (18.00)
`14.36 (4.32)
`14.12 (4.04)
`14.49 (4.46)
`9.54(3.36)
`9.57 (2.95)
`9,53 (3.56)
`
`Change:
`mean (SD)
`
`-13.11 (8.53)
`13.62 (8.36)
`12.85 (8.64)
`-4.98 (7.61)
`4.15 (8.18)
`~5.40 (7.30)
`-1.20 (1.16)
`-1.23 (1.24)
`-1.19 (1.12)
`-1.48 (1.25)
`-1.61 (1.23)
`~1.42 (1.26)
`-0.50 (1.33)
`-0.35 (1.46)
`0.58 (1.26)
`12.90(15.72)
`14,03 (15.15)
`-12.34 (16.02)
`-3.08 (4.12)
`-3.39 (4.10)
`-2.92 (4.13)
`-2.99 (3.62)
`-3.49 (3.40)
`-2.73 (3.71)
`
`Baseline:
`mean (SD)
`22.67(5.15)
`22.22 (4.65)
`22.76(5.31)
`13.54 (7.63)
`10.90(6.54)
`15.04 (7.89)
`4.18 (0.72)
`4,00 (0.71)
`4.28 (0.72)
`4.13 (0.70)
`4.02 (0.69)
`4.18 (0.70)
`2.62 (1.37)
`2.07 (1.08)
`2.93 (1.44)
`61.75 (15.51)
`58,63 (13.27)
`63.31 (16.50)
`14.50(3.90)
`14.41 (3.76)
`14.50 (4.00)
`9.58(3.11)
`9.49 (2,93)
`9.57 (3.20)
`
`Change:
`mean (SD)
`-9.10 (9.36)
`-10.39(8.69)
`-8.39 (9.76)
`~0.89 (6.90)
`1.32 (5.19)
`-0.67(7.77)
`-0.89 (1.31)
`0.98 (1.44)
`0.82 (1.24)
`-1.16 (1.39)
`-1.10 (1.55)
`=1.18 (1.31)
`0.12 (1.45)
`0.10 (1.16)
`0.17 (1.58)
`6.96 (16.39)
`-9.02 (12.59)
`-5.86 (18.28)
`-2.29 (4.23)
`-3.37(4.07)
`1.72 (4.24)
`-1.69 (3.66)
`-2.05 (3.07)
`-1.49(3.98)
`
`*YMRSindicates Young Mania Rating Scale; HAMD-21, Hamilton Depression Rating, 21-ltem; CGI-BP, Clinical Global Impressions—Severity of Bipolar Disorder;
`and PANSS,Positive and Negative Syndrome Scale.
`fAll tests based on 1 df.
`Treatmentdifference, olanzapine cotherapy vs monotherapy;derived from analysis of variance.
`
`aboutsignificantly greater improvement than mono-
`therapy onpatients’ last observation carried forward, Posi-
`tive and Negative SyndromeScaletotal, and Hostility item
`scores, as well as on the CGI-BP overall and Severity of
`Depression scores (Table 3).
`
`SUBGROUP ANALYSES
`
`Subgroupanalyses, defined a priori, were conducted on
`baseline to end point YMRS total scores. Nosignificant
`interactions were seen between previous exposureto psy-
`chotropics (antidepressants, antipsychotics) and therapy
`(cotherapy, monotherapy). However, amongall pa-
`tients without psychotic features, olanzapine cotherapy
`was significantly moreefficacious than monotherapy(co-
`therapy: -13.25 [7.76], n=150; monotherapy: -8.32
`[8.68], n=76; Fy j96= 16.97; P<.001). Among patients
`without psychotic features, olanzapine cotherapy was
`moreeffective than monotherapy regardless of whether
`patients received lithium or valproate. However, among
`patients with psychotic features, responses to treatment
`were not different between the cotherapy and mono-
`therapy groups regardless of whether patients received
`lithium or valproate—this despite the lack of associa-
`tion between the presence of psychotic features and the
`differential effect of therapy (ANOVAtestof interac-
`tion: F,374=0.60; P=.44).
`Amongpatients with a current mixedepisode,olan-
`zapine cotherapy was superior to monotherapy (co-
`
`therapy: -12.92 [8.37], n=121; monotherapy: -7.46
`[10.15], n=54; Fy iyg=17.31; P<.OOL). However, among
`patients presenting with pure mania,the treatmentdif-
`ference did not achievestatistical significance (co-
`therapy: -13.34 [8.77], n=99; monotherapy: -10.57
`[8.40], n=60;F,j29=2.95; P=.09). The superiority ofolan-
`zapine cotherapy over monotherapyseenin patients with
`mixed episodes was foundonlyin patients receivingval-
`proate (cotherapy: -13.18, [8.49], n=84; monotherapy:
`-7.48 [10.74], n=42; Fi124= 10.53; P=.002), whereas the
`treatment difference seen with lithium did not achieve
`statistical significance (cotherapy: -12.32 [8.15], n=37;
`monotherapy: -7.42 [8.14], n=12; F,47=3.28; P=.08),
`again despite the lack of association between course of
`illness and thedifferential effect of therapy (ANOVAtest
`of interaction, F,274=0.14; P=.71).
`Finally, amongpatients receiving valproate, olanza-
`pine cotherapy brought aboutsignificantly greater im-
`provement in YMRS total scores compared with patients
`receiving valproate monotherapy (cotherapy: -12.85 [8.64],
`n=146; monotherapy: -8.39 [9.76], n=72; Fy :ss= 13.44;
`P<.001). Amongpatients receiving lithium, the greater
`improvementseen with olanzapine cotherapyrelative to
`monotherapydid notachievestatistical significance (co-
`therapy: -13.62 [8.36], n=74; monotherapy: —-10.39 [8.69],
`n=41; Fyg6=3.74; P=.06). The type of moodstabilizer was
`not associatedsignificantly witha differential effect of co-
`therapy compared with monotherapy (ANOVAtestof in-
`teraction, F, 373=0.74; P=.39).
`
`(REPRINTED) ARCH GEN PSYCHIATRY/VOL59, JAN 2002
`5 ors
`©2002 American Medical Association, All rights reserved.
`
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`5.9
`
`Table 4. Treatment-Emergent Adverse Events*
`
`Event (COSTART Term)
`Somnolence
`
`Ory mouth
`
`Weight gain
`
`Increased appetite
`
`Tremor
`
`Asthenia
`
`Depression
`
`Headache
`
`Dizziness
`
`Diarrhea
`
`Nervousness
`
`Thirst
`
`Speech disorder
`
`Monotherapy
`(n = 115)
`(%)
`27.0
`
`P Valuet
`
`MoodStabilizer
`
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`Full sample
`Lithium
`Valproate
`
`Olanzapine Cotherapy
`(n = 229)
`(%)
`51.5
`51.3
`51.6
`31.9
`25.0
`35.3
`26.2
`21.1
`28.8
`23.6
`15.8
`27.5
`23.1
`25.0
`22.2
`18.3
`23.7
`15.7
`17.9
`18.4
`17.6
`15.7
`13.2
`17.0
`13.5
`79
`16.3
`11.8
`11.8
`11.8
`10.5
`10.5
`10.5
`10.0
`5.3
`
`79
`
`*Incidence in the olanzapine group greater than or equal to 10% orstatistically significantly greater than placebo.
`tTreatmentdifference, olanzapine cotherapy vs monotherapy; derived from the Fisher exacttest.
`
`RISKS
`
`Nostatistically significant changes from baseline were
`seen in extrapyramidal symptoms on the Simpson—-
`AngusScale, AbnormalInvoluntary MovementScale, and
`Barnes Akathisia Scale. Rates of adverse events (Table 4)
`more frequently reported in the cotherapy group in-
`cluded somnolence, dry mouth, weight gain, increased
`appetite, tremor, and speechdisorder(cotherapy: slurred
`speech n= 14,speaking difficulties n=1; monotherapy:
`stuttering n=1). In the cotherapy group,25 patients dis-
`continued treatment due to adverse events (Table 1). Six
`(2.6%) discontinued due to somnolence, 3 (1.3%) due
`to weight gain, and 3 (1.3%) due to peripheral edema.
`The remaining 13 discontinuing patients in the olanza-
`pine cotherapy group withdrew dueto 13 different ad-
`verse events (1 patient per event class). The 2 patients
`(1.7%) in the monotherapy group whodiscontinued both
`withdrew due to depression (Table 1). Post hoc sub-
`
`group analysis showedthat, amongpatients receiving val-
`proate,a significantly higher incidence of the adverse event
`“dizziness” was seen in patients receiving cotherapy
`(16.3% vs 4.1%; P=.009).
`Nostatistically or clinically significant differences
`emerged between the monotherapy and olanzapine co-
`therapy groupsfor changes in vital signs. However,the co-
`therapy group experienceda 3.6% increasein body weight,
`significantly higher than that seen in the monotherapy group
`(cotherapy: 3.08 [3.04] kg, n=219; monotherapy: 0.23
`[2.48] kg, n=113; F,392=73.88; P<.001). With the excep-
`tion ofa greater incidence of treatment-emergentelevated
`prolactin levels (upper limit: 0.81 nmol/L for men, 1.05
`nmol/L for women) at end point in the cotherapy group
`(19.1% vs 4.3%; P=.001), there were no otherstatisti-
`cally andclinically significant differences in treatment-
`emergentlaboratory test result abnormalities at end point,
`including nonfasting glucoselevels, between the olanza-
`pine cotherapy group and the monotherapy group.
`
`(REPRINTED) ARCH GEN PSYCHIATRY/VOL59, JAN 2002
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`6 of 8
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`—_kim”
`include the presence of depressive symptoms maypar-
`ticularly benefit from the addition of olanzapine.
`Overall YMRS responsesto cotherapy with valproate
`were similar in magnitudeto responses to cotherapy with
`lithium. On a numericbasis, response to lithium mono-
`therapy waslarger than the response to valproate mono-
`therapy. This, plus the larger numberof patients receiv-
`ing valproate, might explain the significant difference
`between responses to valproate cotherapy vs valproate
`monotherapyand the nonsignificant difference betweenre-
`sponses to lithium cotherapyvslithium monotherapy.
`Adverse events occurringata significantly higher rate
`in the cotherapy group and severe enoughto resultin dis-
`continuation included somnolence and weight gain. Im-
`portantly, however, the olanzapine cotherapy group did
`not experiencea significant increase in nonfasting plasma
`glucoselevels or any treatment-emergent hyperglycemia.
`Weight gain during treatment with olanzapine has been
`described previously.”°?) However, lithium and valpro-
`ate are both knowntobe associated with weight gain.”
`Weight gain in the cotherapy group was similarto that re-
`ported for olanzapine monotherapy, suggestingthat there
`is no clear synergism between olanzapine andeitherlithium
`or valproate in causing weightgain.
`Ourstudy has severallimitations. First, assignment
`to valproateorlithium was not randomized butreflected
`the treatmentpreferences ofclinicians and investigators.
`The larger recruitmentof patients receiving valproate
`monotherapyreflects the current practice in the United
`States of a more extensive use ofvalproate than lithium
`by patients who havebipolar disorder with manic or mixed
`episodes. Because the study was not poweredto showsig-
`nificantdifferences in the primary outcomevariablesstrati-
`fied by moodstabilizer, significantdifferences were found
`only when comparisons were made between mono-
`therapy and cotherapy;few differences were found when
`patients werestratified by moodstabilizer. Second, our
`sample wasrestricted to partial respondersto lithium or
`valproate. Patients received monotherapy for only 2 weeks,
`with mean bloodlevels of 0.76 mmol/L and 63.6 pg/mL
`for lithium and valproate, respectively. In clinical prac-
`tice, practitioners may be inclined to maximize the dose
`ofmonotherapytreatmentbeforeinitiating cotherapytreat-
`ment. Finally, the lack of an olanzapine-monotherapy arm
`prevented us from consideringa possible synergistic effect
`between olanzapine and the moodstabilizer. Moreover,
`the lack of a comparator arm, such as a moodstabilizer
`plus anotheragent,also limits our conclusions aboutolan-
`zapine’s unique effects when added to moodstabilizers.
`It would be of considerable benefit to investigate the ef-
`ficacy of olanzapine cotherapy vs a combination therapy
`consisting oflithium plus valproate, thereby more accu-
`rately reflecting current clinical practice.
`In summary,our findings suggest that, in patients
`with bipolar manic or mixed episodes who demonstrate
`inadequate responsivenessto at least 2 weeks of mood-
`stabilizer monotherapy, the combination oflithium or
`valproate plus olanzapine may provide additional effi-
`cacy compared with either agent alone. Patients treated
`with combination therapy experienced more adverse
`events but none seemedto belife-threatening. The re-
`sponse in patients without psychotic features and the im-
`
`This double-blind, placebo-controlled study suggests that,
`in patients with inadequate responsesto at least 2 weeks
`of lithium or valproate monotherapy, the addition of olan-
`zapine may confer additionalsignificantefficacy. No sig-
`nificant changes were seen in extrapyramidal symp-
`toms but a numberof adverse events were reported more
`frequently by patients receiving cotherapy.
`Thefindings in this patient population, character-
`ized as partially nonresponsive to monotherapy, are com-
`parable with those of Maller-Oerlinghausenet al,° who
`comparedtheefficacy of combined therapy with con-
`ventional antipsychotics and valproate vs valproate mono-
`therapy in patients with bipolar or schizoaffective dis-
`order. Sachs!® recently reported preliminary results
`comparing the addition of risperidone, haloperidol, or
`placeboto lithium or valproate, and found that the ad-
`ditionofrisperidone showeda significantly improvedre-
`sponse compared with monotherapy.
`Considering the exclusion of patients who showed a
`responseafter 2 weeks of monotherapy, our patient popu-
`lation should be classified as lithium- or valproate-
`nonresp