Asenapine (Monograph)
Brand name: Saphris
Drug class: Atypical Antipsychotics
VA class: CN709
Chemical name: (3aRS,12bRS)-5-Chloro-2,3,3a,12b-tetrahydro-2-methyl-1H-dibenz[2,3:6,7]oxepino[4,5-c]pyrrole (2Z)-2-butenedioate (1:1)
Molecular formula: C17H16ClNO•C4H4O4
CAS number: 85650-56-2
Warning
- Increased Mortality in Geriatric Patients with Dementia-related Psychosis
-
Geriatric patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.1 28 39 73 75
-
Asenapine is not approved for the treatment of patients with dementia-related psychosis.1 39 73 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis under Cautions.)
Introduction
Dibenzo-oxepino pyrrole derivative; atypical or second-generation antipsychotic agent.1 4 6 8 28 74 85
Uses for Asenapine
Schizophrenia
Acute and maintenance treatment of schizophrenia in adults.1 2 4 82 84 88 89 93
American Psychiatric Association (APA) considers most atypical antipsychotic agents first-line drugs for management of the acute phase of schizophrenia (including first psychotic episodes).28
Patients who do not respond to or tolerate one drug may be successfully treated with an agent from a different class or with a different adverse effect profile.28 70 71 72
Bipolar Disorder
Acute treatment as monotherapy or adjunctive therapy with lithium or valproate of manic or mixed episodes associated with bipolar I disorder (with or without psychotic features).1 3 5 74 94 99 100
Maintenance treatment as monotherapy of bipolar I disorder.1 5 86
Asenapine Dosage and Administration
Administration
Sublingual Administration
Administer tablets sublingually twice daily.1
Do not remove sublingual tablet from blister pack until just prior to administration.1 With dry hands, pull blister pack out of case and peel back colored tab to expose the tablet; do not push tablet through blister pack.1 Gently remove tablet and place under the tongue, then allow to dissolve completely (usually takes about 10 seconds).1 6
Do not eat or drink for 10 minutes following administration.1 74 Do not split, crush, chew, or swallow the sublingual tablets.1 (See Food and Water under Pharmacokinetics.)
Dosage
Available as asenapine maleate; dosage expressed in terms of asenapine.1 4 81
Pediatric Patients
Bipolar Disorder
Manic and Mixed Episodes: Monotherapy
SublingualChildren and adolescents 10–17 years of age: Initially, 2.5 mg twice daily.1 Recommended target dosage is 2.5–10 mg twice daily.1 Based on individual patient response and tolerability, may increase to 5 mg twice daily after 3 days and then to 10 mg twice daily after 3 additional days.1 Carefully titrate dosage to reduce risk of dystonia.1 (See Pediatric Use under Cautions.) Safety of dosages >10 mg twice daily not evaluated.1
Adults
Schizophrenia
Sublingual
For acute treatment, recommended initial and target dosage is 5 mg twice daily.1 May increase to 10 mg twice daily after 1 week based on tolerability.1 The higher dosage (10 mg twice daily) did not provide additional therapeutic benefit in clinical trials, but was clearly associated with increased adverse effects.1 82 Safety of dosages >10 mg twice daily not evaluated.1
For maintenance treatment, recommended target dosage range is 5–10 mg twice daily.1
In patients with remitted first or multiple episodes, APA recommends either indefinite maintenance therapy or gradual discontinuance of the antipsychotic with close follow-up and a plan to reinstitute treatment upon symptom recurrence.28 Consider antipsychotic therapy discontinuance only after ≥1 year of symptom remission or optimal response while receiving the drug.28 Indefinite maintenance treatment recommended if patient has experienced multiple previous psychotic episodes or 2 episodes within 5 years.28
Bipolar Disorder
Manic and Mixed Episodes: Monotherapy or Combination Therapy
SublingualMonotherapy for acute treatment: Initial and target dosage is 5–10 mg twice daily.1 3 83 Safety of dosages >10 mg twice daily not evaluated.1
Adjunctive therapy with lithium or valproate for acute treatment: Initially, 5 mg twice daily.1 May increase dosage to 10 mg twice daily based on clinical response and tolerability.1 Safety of dosages >10 mg twice daily not evaluated.1
In responsive patients, continue drug therapy beyond the acute response.1
Monotherapy for maintenance treatment: Continue same dosage used during stabilization (5–10 mg twice daily).1 Based on clinical response and tolerability, may decrease 10-mg twice-daily dosage to 5 mg twice daily.1 Safety of dosages >10 mg twice daily not evaluated.1
Prescribing Limits
Pediatric Patients
Bipolar Disorder
Manic and Mixed Episodes
SublingualSafety of dosages >10 mg twice daily not evaluated.1
Adults
Schizophrenia
Sublingual
Safety of dosages >10 mg twice daily not evaluated.1
Bipolar Disorder
Manic and Mixed Episodes
SublingualSafety of dosages >10 mg twice daily not evaluated.1
Special Populations
Hepatic Impairment
Severe hepatic impairment (Child-Pugh class C): Use is contraindicated.1 7 95
Mild (Child-Pugh class A) or moderate (Child-Pugh class B) hepatic impairment: Dosage adjustment not necessary.1 7 95 (See Absorption: Special Populations, under Pharmacokinetics.)
Renal Impairment
Routine dosage adjustment not required.1 7 95 (See Absorption: Special Populations, under Pharmacokinetics and also see Elimination: Special Populations, under Pharmacokinetics.)
Geriatric Patients
Routine dosage adjustment not required.1 (See Geriatric Use under Cautions and also see Absorption: Special Populations, under Pharmacokinetics.)
Gender, Race, or Smoking Status
Dosage adjustment not routinely required based on gender, race, or smoking status.1
Cautions for Asenapine
Contraindications
-
Severe hepatic impairment (Child-Pugh class C).1
-
Known hypersensitivity to asenapine maleate or any components in the formulation.1 96 (See Hypersensitivity Reactions under Cautions.)
Warnings/Precautions
Warnings
Increased Mortality in Geriatric Patients with Dementia-related Psychosis
Increased risk of death with use of antipsychotic agents in geriatric patients with dementia-related psychosis.1 28 39 73 75
Analyses of 17 dementia-related psychosis placebo-controlled trials in geriatric patients mainly receiving atypical antipsychotic agents revealed an approximate 1.6- to 1.7-fold increase in mortality compared with that in patients receiving placebo.1 73
Most fatalities appeared to result from cardiovascular-related events (e.g., heart failure, sudden death) or infections (mostly pneumonia).1 73
Antipsychotic agents, including asenapine, are not approved for the treatment of dementia-related psychosis.1 39 73 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning; Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis under Cautions; and also see Dysphagia under Cautions.)
Sensitivity Reactions
Hypersensitivity Reactions
Hypersensitivity reactions reported with asenapine.1 96 Symptoms included anaphylaxis, angioedema, hypotension, tachycardia, swollen tongue, dyspnea, wheezing, and rash.1 96 Some cases reported occurrence of more than one hypersensitivity reaction, and several reported hypersensitivity reactions occurring after the first dose.1 96 In some patients, symptoms resolved after asenapine discontinuance; others required hospitalization or emergency room visits and therapeutic interventions.96 (See Contraindications under Cautions and also see Advice to Patients.)
Other Warnings and Precautions
Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis
Increased incidence of adverse cerebrovascular events (cerebrovascular accidents and TIAs), including fatalities, observed in geriatric patients with dementia-related psychosis treated with certain atypical antipsychotic agents (aripiprazole, olanzapine, risperidone) in placebo-controlled studies.1 28 Asenapine is not approved for the treatment of patients with dementia-related psychosis.1 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning.)
Neuroleptic Malignant Syndrome
Neuroleptic malignant syndrome (NMS), a potentially fatal symptom complex characterized by hyperpyrexia, muscle rigidity, delirium, and autonomic instability, reported with antipsychotic agents,1 including asenapine.94
If NMS is suspected, immediately discontinue therapy and provide intensive symptomatic treatment and monitoring.1
Tardive Dyskinesia
Tardive dyskinesia, a syndrome consisting of potentially irreversible, involuntary dyskinetic movements, reported with use of antipsychotic agents, including asenapine.1 84
Reserve long-term antipsychotic treatment for patients with chronic illness known to respond to antipsychotic agents, and for whom alternative, effective, but potentially less harmful treatments are not available or appropriate.1 In patients requiring chronic treatment, use lowest dosage and shortest duration of treatment needed to achieve a satisfactory clinical response; periodically reassess need for continued therapy.1
APA recommends assessing patients receiving atypical antipsychotic agents for abnormal involuntary movements every 12 months; for patients at increased risk for tardive dyskinesia, assess every 6 months.28 Consider discontinuance of asenapine if signs and symptoms of tardive dyskinesia appear.1 However, some patients may require treatment despite the presence of the syndrome.1
Metabolic Changes
Atypical antipsychotic agents, including asenapine, have caused metabolic changes, including hyperglycemia and diabetes mellitus, dyslipidemia, and weight gain.1 While all atypical antipsychotics produce some metabolic changes, each drug has its own specific risk profile.1 (See Hyperglycemia and Diabetes Mellitus, see Dyslipidemia, and also see Weight Gain under Cautions.)
Hyperglycemia and Diabetes Mellitus
Hyperglycemia, sometimes severe and associated with ketoacidosis, hyperosmolar coma, or death, reported in patients receiving atypical antipsychotic agents.1 11 12 14 15 16 17 18 20 21 22 23 25 40 41 42 46 65 Hyperglycemia reported in patients treated with asenapine.1 In short-term controlled trials in patients with schizophrenia or bipolar mania, approximately 0–5 and 6–16% of asenapine-treated patients experienced shifts from normal to high and from borderline to high fasting glucose concentrations, respectively.1 In a longer-term (one-year), comparator-controlled, double-blind study, the mean increase in fasting glucose concentrations from baseline was 2.4 mg/dL.1
Assess blood glucose before or soon after initiation of antipsychotic therapy, then periodically monitor during long-term therapy.1 (See Advice to Patients.)
Dyslipidemia
Undesirable changes in lipid parameters observed in patients treated with some atypical antipsychotics.1 However, asenapine does not substantially affect the lipid profile during short-term therapy.1
Baseline (i.e., before or soon after initiation of therapy) and periodic follow-up fasting lipid evaluations recommended during asenapine therapy.1
Weight Gain
Weight gain observed with atypical antipsychotic therapy, including asenapine.1 84 93
Manufacturer recommends baseline and frequent monitoring of weight during therapy.1 In pediatric patients, monitor weight gain and assess against that expected for normal growth.1
Orthostatic Hypotension, Syncope, and Other Hemodynamic Effects
Risk of orthostatic hypotension and syncope reported with atypical antipsychotics, particularly during initial dosage titration and when dosage is increased.1
In clinical trials in adults, including long-term trials without comparison with placebo, syncope was reported in 0.6% of asenapine-treated patients.1 In short-term bipolar mania trials in pediatric patients, syncope was reported in 1% of patients receiving asenapine 2.5 or 5 mg twice daily and in no patients receiving asenapine 10 mg twice daily.1
Monitor orthostatic vital signs in patients who are susceptible to hypotension (e.g., geriatric patients, patients with dehydration or hypovolemia, patients concomitantly receiving antihypertensive therapy), patients with cardiovascular disease (e.g., history of MI, ischemic heart disease, heart failure, conduction abnormalities), and patients with cerebrovascular disease.1 Use with caution in patients receiving other drugs that can cause hypotension, bradycardia, respiratory depression, or CNS depression (see Interactions).1 In all such patients, consider monitoring of orthostatic vital signs; if hypotension occurs, consider dosage reduction.1
Falls
May cause somnolence, postural hypotension, and motor and sensory instability, which may lead to falls and, consequently, fractures or other injuries.1
In patients with diseases, conditions, or other drugs that could exacerbate these effects, complete fall risk assessments when initiating antipsychotic therapy and repeat such testing periodically during long-term therapy.1
Leukopenia, Neutropenia, and Agranulocytosis
Leukopenia and neutropenia temporally related to antipsychotic agents, including asenapine, reported during clinical trial and/or postmarketing experience.1 78 Agranulocytosis (including fatal cases) also reported with other antipsychotic agents.1
Possible risk factors for leukopenia and neutropenia include preexisting low WBC count or ANC or a history of drug-induced leukopenia or neutropenia.1 78 Monitor CBC during the first few months of therapy in patients with such risk factors.1 Discontinue asenapine at the first sign of a clinically important decline in WBC count in the absence of other causative factors.1
Carefully monitor patients with clinically important neutropenia for fever or other signs and symptoms of infection (e.g., fever) and treat promptly if they occur.1 Discontinue asenapine if severe neutropenia (ANC <1000/mm3) occurs; monitor WBC until recovery occurs.1
Prolongation of QT Interval
Relatively small increases (2–5 msec with asenapine compared with placebo) in corrected QT (QTc) interval observed in adults with schizophrenia in a controlled and dedicated QT study; these increases were slightly lower than those observed in patients receiving quetiapine.1 6 10 During clinical trials, post-baseline QT-interval prolongations >500 msec reported at similar rates for asenapine and placebo; torsades de pointes or adverse effects associated with delayed ventricular repolarization not reported.1
Avoid use in patients concurrently receiving other drugs known to prolong the QTc interval, in patients with a history of cardiac arrhythmias, and in other circumstances that may increase risk of torsades de pointes and/or sudden death (e.g., bradycardia, hypokalemia or hypomagnesemia, presence of congenital QT-interval prolongation).1 (See Drugs that Prolong QT Interval under Interactions.)
Hyperprolactinemia
May cause elevated serum prolactin concentrations, which may persist during chronic administration and cause clinical disturbances (e.g., galactorrhea, amenorrhea, gynecomastia, impotence); chronic hyperprolactinemia associated with hypogonadism may lead to decreased bone density in both females and males.1
If contemplating asenapine therapy in a patient with previously detected breast cancer, consider that approximately one-third of human breast cancers are prolactin-dependent in vitro.1
Seizures
Seizures reported in 0.3% of asenapine-treated adult patients in schizophrenia and bipolar mania clinical trials.1 No seizures reported in pediatric patients in a short-term bipolar mania trial.1
Use with caution in patients with a history of seizures or conditions that may lower seizure threshold; such conditions may be more prevalent in patients ≥65 years of age.1
Cognitive and Motor Impairment
Somnolence, usually transient and with the highest incidence during the first week of therapy, reported in 13–26% of adult patients and 46–53% of pediatric patients receiving asenapine in clinical trials.1 (See Specific Drugs under Interactions and also see Advice to Patients.)
Body Temperature Regulation
Disruption of ability to regulate core body temperature possible with atypical antipsychotic agents, including asenapine; ≤1% of asenapine-treated patients in premarketing clinical trials experienced adverse effects suggestive of body temperature increases (e.g., pyrexia, feeling hot).1
Use caution in patients who will be experiencing conditions that may contribute to an elevation in core body temperature (e.g., strenuous exercise, extreme heat, concomitant use of agents with anticholinergic activity, dehydration).1
Dysphagia
Esophageal dysmotility and aspiration associated with the use of antipsychotic agents.1 Dysphagia reported with asenapine.1 Use with caution in patients at risk for aspiration.1
Specific Populations
Pregnancy
No studies conducted to date in pregnant women.1 No available human data informing the drug-associated risk.1 In animal reproduction studies, asenapine was not teratogenic at dosages 0.7 and 0.4 times, respectively, the maximum recommended human dosage (MRHD).1 In animals, the drug increased post-implantation loss and early pup deaths and decreased subsequent pup survival and weight gain.1 Advise pregnant women of potential risk to the fetus with asenapine exposure.1
Risk for extrapyramidal and/or withdrawal symptoms (e.g., agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, feeding disorder) in neonates exposed to antipsychotic agents during the third trimester.1 90 91 92 Symptoms have varied in severity; some infants recovered within hours to days without specific treatment while others required prolonged hospitalization.1 90 91 92 Monitor neonates for extrapyramidal and/or withdrawal symptoms; if such symptoms occur, manage appropriately.1
National Pregnancy Registry for Atypical Antipsychotics: 866-961-2388 and [Web].1
Lactation
Asenapine distributes into milk in rats; not known whether distributes into human milk.1 Effects of the drug on nursing infants and on milk production also not known.1
Weigh benefit of asenapine therapy to the woman and benefits of breast-feeding against potential risk to infant from exposure to the drug or from the underlying maternal condition.1
Pediatric Use
Safety and efficacy not evaluated in pediatric patients <10 years of age.1
Safety and efficacy of asenapine monotherapy for treatment of bipolar I disorder in pediatric patients 10–17 years of age established.1 100 Such patients appear to be more sensitive to dystonia if initial dosage titration schedule not followed; titrate dosage according to manufacturer's recommended schedule (see Dosage under Dosage and Administration).1 Safety and efficacy as adjunctive therapy for the treatment of bipolar disorder not established in pediatric patients to date.1 (See Elimination: Special Populations, under Pharmacokinetics.)
Efficacy for the treatment of schizophrenia not established in pediatric patients <18 years of age.1 97 In a short-term (i.e., 8 weeks' duration), placebo-controlled trial in adolescents 12–17 years of age with schizophrenia, asenapine (2.5 or 5 mg twice daily) did not substantially improve the PANSS total score compared with placebo.1 97 Tolerability of asenapine in this trial generally was similar to that observed in the pediatric bipolar and adult bipolar and schizophrenia trials.1 97 In addition, no important safety findings reported in a 26-week, open-label, uncontrolled safety trial in pediatric patients with schizophrenia.1 97
Geriatric Use
Insufficient experience in patients ≥65 years of age to determine whether they respond differently than younger adults.1 Risk of poorer tolerance and orthostasis; carefully monitor.1 (See Geriatric Patients under Dosage and Administration and also see Absorption: Special Populations, under Pharmacokinetics.)
Geriatric patients with dementia-related psychosis treated with either conventional or atypical antipsychotic agents are at an increased risk of death;1 28 39 73 75 increased incidence of adverse cerebrovascular events also observed with certain atypical antipsychotic agents.1 74 Asenapine is not approved for the treatment of patients with dementia-related psychosis.1 (See Increased Mortality in Geriatric Patients with Dementia-related Psychosis in Boxed Warning and also see Cerebrovascular Events in Geriatric Patients with Dementia-related Psychosis under Cautions.)
Hepatic Impairment
Substantially higher exposures observed in individuals with severe hepatic impairment (Child-Pugh class C).1 95 Use is therefore contraindicated in such patients.1 95 (See Absorption: Special Populations, under Pharmacokinetics.)
Exposure is not substantially altered in individuals with mild (Child-Pugh class A) or moderate (Child-Pugh class B) hepatic impairment; dosage adjustment is therefore not necessary in such patients.1 95
Renal Impairment
Exposure was similar in individuals with varying degrees of renal impairment and those with normal renal function; dosage adjustment not required.1 95 (See Absorption: Special Populations, under Pharmacokinetics and also see Elimination: Special Populations, under Pharmacokinetics.)
Common Adverse Effects
Adults with schizophrenia (acute treatment): Akathisia (including hyperkinesia),1 6 82 93 oral hypoesthesia,1 6 82 somnolence (including sedation and hypersomnia).1 2 6 82 93 Akathisia appears to be dose related.1 Tolerability profile in the maintenance treatment of schizophrenia was similar to that seen with acute treatment.1 93
Adults with bipolar disorder (acute treatment; monotherapy or adjunctive therapy): Somnolence (including sedation and hypersomnia),1 3 5 6 74 83 94 oral hypoesthesia,1 dizziness,1 3 5 6 74 83 extrapyramidal symptoms other than akathisia (e.g., dystonia, blepharospasm, torticollis, dyskinesia, tardive dyskinesia, muscle rigidity, parkinsonism, gait disturbance, masked facies, tremor),1 3 6 83 94 akathisia.1 All common adverse effects appear to be dose related.1 Tolerability profile in the maintenance treatment of manic or mixed episodes associated with bipolar 1 disorder was similar to that seen with acute treatment.1
Pediatric patients with bipolar disorder (acute treatment; monotherapy): Somnolence (including sedation and hypersomnia),1 dizziness,1 dysgeusia,1 oral hypoesthesia,1 nausea,1 increased appetite,1 fatigue,1 weight gain.1 Frequency of fatigue appears to be dose related.1
Drug Interactions
Metabolized mainly by direct glucuronidation by UGT1A4 and oxidative metabolism by CYP isoenzymes, principally by CYP1A2 and, to a lesser extent, by CYP3A4 and CYP2D6.1 3 6 7 Weakly inhibits CYP2D6; does not appear to induce CYP1A2 or CYP3A4.1
Drugs Affecting or Metabolized by Hepatic Microsomal Enzymes
Drugs that are both substrates and inhibitors of CYP2D6: Clinically important pharmacokinetic interactions possible.1 7 (See Specific Drugs under Interactions.)
Potent CYP1A2 inhibitors: Possible increased asenapine exposure; dosage reduction of asenapine based on clinical response may be necessary.1 98
Drugs that Prolong QT Interval
Potential additive effect on QT-interval prolongation; avoid concomitant use of other drugs known to prolong QTc interval.1 10 76 77 79 (See Prolongation of QT Interval under Cautions.)
Hypotensive Agents and Drugs causing Bradycardia
May enhance hypotensive effects of certain antihypertensive agents and other drugs that can cause hypotension or bradycardia.1 Use concomitantly with caution; consider monitoring orthostatic vital signs during concurrent use.1 (See Orthostatic Hypotension, Syncope, and Other Hemodynamic Effects under Cautions and also see Specific Drugs under Interactions.)
Monitor BP during concurrent use of hypotensive agents.1 If hypotension develops, consider reducing dosage of asenapine.1 Adjust dosage of hypotensive agents, if necessary, based on BP.1 (See Orthostatic Hypotension, Syncope, and Other Hemodynamic Effects under Cautions and also see Advice to Patients.)
Specific Drugs
Drug |
Interaction |
Comments |
---|---|---|
Antiarrhythmics (class Ia and III; e.g., amiodarone, procainamide, quinidine, sotalol) |
Increased risk of QT-interval prolongation1 |
Avoid concomitant use1 |
Anticholinergic agents |
Possible disruption of body temperature regulation1 |
Use with caution1 |
Antipsychotic agents that prolong QT interval (e.g., chlorpromazine, haloperidol, olanzapine, paliperidone, pimozide, quetiapine, thioridazine, ziprasidone) |
Avoid concomitant use1 |
|
Carbamazepine |
Carbamazepine slightly decreased peak asenapine concentrations and AUC1 7 |
|
Cimetidine |
Cimetidine (inhibitor of CYP3A4, CYP2D6, and CYP1A2) slightly decreased peak concentrations of asenapine and very slightly increased asenapine AUC1 7 |
|
Ciprofloxacin |
Possible increased asenapine exposure;1 98 dystonia reported in asenapine-treated patient after ciprofloxacin (CYP1A2 inhibitor) was initiated98 |
Asenapine dosage reduction based on clinical response may be necessary1 98 |
CNS agents |
Possible additive CNS depressant effects, including increased fall risk1 |
Use concomitantly with caution1 Perform fall risk assessments (see Falls under Cautions)1 |
Fluvoxamine |
Fluvoxamine (potent CYP1A2 inhibitor) slightly increased peak asenapine concentrations and AUC at a suboptimal dosage; therapeutic fluvoxamine dosage may cause a greater increase in asenapine concentrations1 7 |
Asenapine dosage reduction based on clinical response may be necessary1 |
Gatifloxacin |
Increased risk of QT-interval prolongation1 |
Avoid concomitant use1 |
Hypotensive agents |
Additive hypotensive effects1 |
Use concomitantly with caution;1 monitor BP and consider monitoring orthostatic vital signs Adjust dosage of hypotensive agent if hypotension develops1 |
Imipramine |
Imipramine (CYP1A2, CYP2C19, and CYP3A4 inhibitor) slightly increased peak asenapine concentrations and AUC1 Asenapine did not affect concentrations of imipramine’s metabolite, desipramine (CYP2D6 substrate)1 7 |
Asenapine dosage adjustment not required1 |
Lithium |
Pharmacokinetics of asenapine not affected; asenapine does not appear to affect lithium concentrations1 |
Asenapine dosage adjustment not required1 |
Moxifloxacin |
Increased risk of QT-interval prolongation1 |
Avoid concomitant use1 |
Paroxetine |
Twofold increase in peak concentrations and exposure of paroxetine (CYP2D6 substrate and inhibitor)1 7 Slight decrease in peak asenapine concentrations and AUCs1 7 |
Reduce paroxetine dosage by half if used concomitantly; asenapine dosage adjustment not required1 |
Smoking |
Pharmacokinetic interaction unlikely1 |
Dosage adjustment based on smoking status not necessary1 |
Tetrabenazine |
Increased risk of QT-interval prolongation79 |
|
Valproic acid |
Valproate slightly increased peak asenapine concentrations and slightly decreased asenapine AUCs; asenapine does not appear to affect valproate concentrations1 |
Asenapine dosage adjustment not required1 |
Asenapine Pharmacokinetics
Absorption
Bioavailability
Administered sublingually because of the low bioavailability (<2%) and extensive first-pass metabolism observed following oral administration of tablets.1 4 6 74
Rapidly absorbed in the sublingual, supralingual, and buccal mucosa following sublingual administration; peak plasma concentrations occur within 0.5–1.5 hours.1 3 6 10 74
Absolute bioavailability of sublingual tablets (5 mg) is 35%.1 3 74
Steady-state plasma concentrations reached within 3 days with twice-daily administration.1
Food and Water
Food ingestion immediately before or 4 hours after sublingual administration of a single 5-mg dose in adults decreased exposure by 20 or 10%, respectively, probably due to increased hepatic blood flow.1
Water intake 2 and 5 minutes following sublingual administration of asenapine 10 mg in adults decreased exposure by 19 and 10%, respectively; effects of water intake 10 or 30 minutes after administration were equivalent.1 (See Administration under Dosage and Administration.)
Special Populations
Smoking does not affect exposure.1
In individuals with mild (Child-Pugh class A) or moderate (Child-Pugh class B) hepatic impairment, exposure was similar to those with normal hepatic function.1 In individuals with severe hepatic impairment (Child-Pugh class C), exposures were an average of 7 times higher compared with individuals with normal hepatic function.1 95
In individuals with varying degrees of renal impairment, exposure of asenapine was similar to individuals with normal renal function.1 95
In geriatric patients, exposure was 30–40% higher compared with younger adult patients.1
Distribution
Extent
Rapidly distributed; large volume of distribution indicates extensive extravascular distribution.1 74
Distributes into milk in rats; not known whether asenapine and/or its metabolites distribute into milk in humans.1
Plasma Protein Binding
95% to plasma proteins (including albumin and α1-acid glycoprotein).1 74
Elimination
Metabolism
Metabolized mainly through direct glucuronidation by UGT1A4 and oxidative metabolism, primarily by CYP1A2 and, to a lesser extent, by CYP3A4 and CYP2D6.1 3 6 7
Metabolites (primarily asenapine N-glucuronide, also N-desmethylasenapine and N-desmethylasenapine N-carbamoyl glucuronide) are largely inactive.1 3 7
Elimination Route
Following administration of a single radiolabeled dose, about 90% of the dose was recovered; approximately 50% recovered in urine and 40% in feces.1
Half-life
Terminal phase half-life (t½β) averages about 24 hours.1 74
Special Populations
Effect of renal function on elimination of metabolites and effect of hemodialysis on pharmacokinetics not evaluated.1
Pharmacokinetics in pediatric patients 10–17 years of age generally similar to those in adults.1
Stability
Storage
Sublingual
Tablets
20–25°C (may be exposed to 15–30°C).1
Actions
-
Exact mechanism of asenapine in schizophrenia and bipolar disorder unknown; efficacy in schizophrenia may be mediated through a combination of antagonist activity at central dopamine type 2 (D2) and serotonin type 2 (5-hydroxytryptamine [5-HT2A]) receptors.1 2 6 7 8 89
-
Exhibits high affinity for serotonin 5-HT1A, 5-HT1B, 5-HT2A, 5-HT2B, 5-HT2C, 5-HT5A, 5-HT6, and 5-HT7 receptors; dopamine D1, D2A, D2B, D3, and D4 receptors; α1A-, α2A-, α2B-, and α2C-adrenergic receptors; and histamine H1 receptors (moderate affinity for H2 receptors).1 2 3 6 7 8 9 74 85 Asenapine acts as an antagonist at these receptors in vitro.1 85
-
Possesses no appreciable affinity for muscarinic cholinergic receptors1 2 3 6 7 8 9 74 85 or β-adrenergic receptors.7
Advice to Patients
-
Importance of advising patients and caregivers that elderly patients with dementia-related psychosis treated with antipsychotic agents are at an increased risk of death.1 28 39 73 Patients and caregivers also should be informed that asenapine is not approved for treating elderly patients with dementia-related psychosis.1 73
-
Risk of serious allergic reactions.1 96 Importance of informing patients of signs and symptoms of such reactions (e.g., difficulty breathing; swelling of the face, tongue, or throat; lightheadedness; itching) and to immediately seek emergency medical attention if they develop.1 96
-
Importance of informing patients that application site reactions (e.g., oral ulcers, blisters, peeling/sloughing, inflammation), primarily in the sublingual area, have been reported.1 Instruct patients to monitor for such reactions during therapy.1
-
Risk of somnolence (i.e., sleepiness, drowsiness).1 Importance of advising patients to exercise caution when performing activities requiring mental alertness (e.g., driving, operating hazardous machinery) until they gain experience with the drug’s effects.1
-
Importance of informing patients and caregivers about the risk of NMS, which can cause high fever, stiff muscles, sweating, fast or irregular heart beat, change in BP, and confusion.1
-
Importance of informing patients about the risk of metabolic changes (e.g., hyperglycemia and diabetes mellitus, dyslipidemia, weight gain), how to recognize symptoms of hyperglycemia and diabetes mellitus, and the need for specific monitoring for such changes, including blood glucose, lipids, and weight, during therapy.1
-
Risk of orthostatic hypotension and syncope (fainting), especially when initiating or reinitiating treatment or increasing the dosage.1 Importance of informing patients about interventions that may help (e.g., sitting on the edge of the bed for several minutes before standing in the morning, slowly rising from a seated position).1
-
Risk of leukopenia/neutropenia.1 Importance of advising patients with a preexisting low WBC count or history of drug-induced leukopenia/neutropenia that their CBC count should be monitored during asenapine therapy.1
-
Importance of informing patients in whom chronic asenapine use is contemplated of risk of tardive dyskinesia.1 67 Importance of advising patients to report any muscle movements that cannot be stopped to a healthcare professional.67
-
Importance of informing patients that oral hypoesthesia, oral paresthesia, and/or dysgeusia (abnormal or altered taste) may occur and that these effects are not serious and are typically transient (i.e., resolving within 1 hour) following sublingual administration.1 74 81 88
-
Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses (e.g., cardiovascular disease, diabetes mellitus, seizures).1
-
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1 92 Importance of clinicians informing patients about the benefits and risks of taking antipsychotics during pregnancy (including that third trimester use of asenapine may cause extrapyramidal and/or withdrawal symptoms in neonates) and about the pregnancy exposure registry (see Pregnancy under Cautions).1 92 Importance of advising patients not to stop taking asenapine if they become pregnant without consulting their clinician; abruptly discontinuing antipsychotic agents may cause complications.92
-
Importance of avoiding overheating or dehydration.1
-
Importance of correctly taking sublingual tablets.1 Do not remove sublingual tablet from the blister pack until just before administration.1 With dry hands, pull blister pack out of case, peel back the colored tab on the pack, and gently remove the tablet.1 Place the sublingual tablet under the tongue and allow to dissolve completely.1 Importance of sliding the blister pack back into the case until it clicks after use.1 Importance of not eating or drinking for 10 minutes following administration.1 74 (See Food and Water under Pharmacokinetics.)
-
Importance of informing patients of other important precautionary information.1 (See Cautions.)
Preparations
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
Routes |
Dosage Forms |
Strengths |
Brand Names |
Manufacturer |
---|---|---|---|---|
Sublingual |
Tablets |
2.5 mg (of asenapine) |
Saphris Black Cherry Flavor |
Allergan |
5 mg (of asenapine) |
Saphris Black Cherry Flavor |
Allergan |
||
10 mg (of asenapine) |
Saphris Black Cherry Flavor |
Allergan |
AHFS DI Essentials™. © Copyright 2024, Selected Revisions November 13, 2017. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.
References
1. Allergan USA, Inc. Saphris (asenapine maleate) sublingual tablets prescribing information. Irvine, CA; 2017 Feb.
2. Potkin SG, Cohen M, Panagides J. Efficacy and tolerability of asenapine in acute schizophrenia: a placebo- and risperidone-controlled trial. J Clin Psychiatry. 2007; 68:1492-500. http://www.ncbi.nlm.nih.gov/pubmed/17960962?dopt=AbstractPlus
3. McIntyre RS, Cohen M, Zhao J et al. A 3-week, randomized, placebo-controlled trial of asenapine in the treatment of acute mania in bipolar mania and mixed states. Bipolar Disord. 2009; 11:673-86. http://www.ncbi.nlm.nih.gov/pubmed/19839993?dopt=AbstractPlus
4. Food and Drug Administration. FDA Psychopharmacologic Drugs Advisory Committee Meeting: Saphris (asenapine) sublingual tablets (NDA 22-117). Rockville, MD; Jul 2009. From FDA web site. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/PsychopharmacologicDrugsAdvisoryCommittee/UCM173876.pdf
5. McIntyre RS, Cohen M, Zhao J et al. Asenapine versus olanzapine in acute mania: a double-blind extension study. Bipolar Disord. 2009; 11:815-26. http://www.ncbi.nlm.nih.gov/pubmed/19832806?dopt=AbstractPlus
6. Citrome L. Asenapine for schizophrenia and bipolar disorder: a review of the efficacy and safety profile for this newly approved sublingually absorbed second-generation antipsychotic. Int J Clin Pract. 2009; 63:1762-84. http://www.ncbi.nlm.nih.gov/pubmed/19840150?dopt=AbstractPlus
7. Weber J, McCormack PL. Asenapine. CNS Drugs. 2009; 23:781-92. http://www.ncbi.nlm.nih.gov/pubmed/19689168?dopt=AbstractPlus
8. Bishara D, Taylor D. Asenapine monotherapy in the acute treatment of both schizophrenia and bipolar I disorder. Neuropsychiatr Dis Treat. 2009; 5:483-90. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2762364&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/19851515?dopt=AbstractPlus
9. Bishara D, Taylor D. Upcoming agents for the treatment of schizophrenia: mechanism of action, efficacy and tolerability. Drugs. 2008; 68:2269-92. http://www.ncbi.nlm.nih.gov/pubmed/18973393?dopt=AbstractPlus
10. Chapel S, Hutmacher MM, Haig G et al. Exposure-response analysis in patients with schizophrenia to assess the effect of asenapine on QTc prolongation. J Clin Pharmacol. 2009; 49:1297-308. http://www.ncbi.nlm.nih.gov/pubmed/19843656?dopt=AbstractPlus
11. Eli Lilly and Company. Zyprexa (olanzapine) tablets and Zyprexa Zydis (olanzapine) orally disintegrating tablets prescribing information. Indianapolis, IN; 2004 Sep 22.
12. Eli Lilly and Company. Lilly announces FDA notification of class labeling for atypical antipsychotics regarding hyperglycemia and diabetes. Indianapolis, IN; 2003 Sep 17. Press release.
13. Dixon L, Perkins D, Calmes C. Guideline watch (September 2009): practice guideline for the treatment of patients with schizophrenia. American Psychiatric Association. Arlington, VA; 2009 Sep. From the American Psychiatric Association web site. http://psychiatryonline.org/guidelines.aspx
14. Novartis Pharmaceuticals. Clozaril (clozapine) prescribing information. East Hanover, NJ; 2003 Dec.
15. AstraZeneca Pharmaceuticals. Seroquel (quetiapine fumarate) tablets prescribing information. Wilmington, DE; 2004 Jul.
16. Janssen Pharmaceutica. Risperdal (risperidone) tablets and oral solution prescribing information. Titusville, NJ; 2003 Oct.
17. Pfizer Inc. Geodon (ziprasidone) prescribing information. New York, NY; 2004 Aug.
18. Lewis-Hall F. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Princeton, NJ: Bristol-Myers Squibb Company; 2004 Mar 25. From FDA website. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm165253.htm
19. Bess AL, Cunningham SR. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2004 Apr 1. From the FDA website. http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM166139.pdf
20. Eisenberg P. Dear health care professional letter regarding safety data on Zyprexa (olanzapine) – hyperglycemia and diabetes. Indianapolis, IN: Eli Lilly and Company; 2004 Mar 1. From the FDA website. http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM166545.pdf
21. Macfadden W. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Wilmington, DE: AstraZeneca Pharmaceuticals; 2004 Apr 22. From the FDA website. http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM166523.pdf
22. Mahmoud RA. Dear health care professional letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. Titusville, NJ: Janssen Pharmaceutica, Inc; 2004. From the FDA website. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm166518.htm
23. Clary CM. Dear health care practitioner letter regarding class labeling for atypical antipsychotics and risk of hyperglycemia and diabetes. New York NY: Pfizer Global Pharmaceuticals; 2004 Aug. From the FDA website. http://www.fda.gov/downloads/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/UCM166433.pdf
24. Cunningham F, Lambert B, Miller DR et al. Antipsychotic induced diabetes in veteran schizophrenic patients. In: Abstracts of the 1st International Conference on Therapeutic Risk Management and 19th International Conference on Pharmacoepidemiology, Philadelphia, PA, 2003 Aug 21-24. Pharmacoepidemiol Drug Saf. 2003; 12(Suppl 1): S154-5.
25. American Diabetes Association; American Psychiatric Association; American Association of Clinical Endocrinologists; North American Association for the Study of Obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. 2004; 27:596-601. http://www.ncbi.nlm.nih.gov/pubmed/14747245?dopt=AbstractPlus
26. Melkersson K, Dahl ML. Adverse metabolic effects associated with atypical antipsychotics. Drugs. 2004; 64:701-23. http://www.ncbi.nlm.nih.gov/pubmed/15025545?dopt=AbstractPlus
27. Citrome LL, Jaffe AB. Relationship of atypical antipsychotics with development of diabetes mellitus. Ann Pharmacother. 2003; 37:1849-57. http://www.ncbi.nlm.nih.gov/pubmed/14632602?dopt=AbstractPlus
28. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, second edition. Am J Psychiatry. 2004; 161(2 Suppl):1-56.
29. Sumiyoshi T, Roy A, Anil AE et al. A comparison of incidence of diabetes mellitus between atypical antipsychotic drugs. J Clin Psychopharmacol. 2004; 24:345-8. http://www.ncbi.nlm.nih.gov/pubmed/15118492?dopt=AbstractPlus
30. Expert Group. ’Schizophrenia and Diabetes 2003’ expert consensus meeting, Dublin, 3–4 October 2003: consensus summary. Br J Psychiatry. 2004; 47(Suppl):S112-4.
31. Young RC, Biggs JT, Ziegler VE et al. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry. 1978; 133:429-35. http://www.ncbi.nlm.nih.gov/pubmed/728692?dopt=AbstractPlus
32. Holt RI. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2086-7. http://www.ncbi.nlm.nih.gov/pubmed/15277449?dopt=AbstractPlus
33. Citrome L, Volavka J. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2087-8. http://www.ncbi.nlm.nih.gov/pubmed/15277450?dopt=AbstractPlus
34. Isaac MT, Isaac MB. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2088. http://www.ncbi.nlm.nih.gov/pubmed/15277451?dopt=AbstractPlus
35. Boehm G, Racoosin JA, Laughren TP et al. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to consensus statement. Diabetes Care. 2004; 27:2088-9. http://www.ncbi.nlm.nih.gov/pubmed/15277452?dopt=AbstractPlus
36. Barrett EJ. Consensus development conference on antipsychotic drugs and obesity and diabetes: response to Holt, Citrome and Volevka, Isaac and Isaac, and Boehm et al. Diabetes Care. 2004; 27:2089-90.
37. Fuller MA, Shermock KM, Secic M et al. Comparative study of the development of diabetes mellitus in patients taking risperidone and olanzapine. Pharmacotherapy. 2002; 23:1037-43.
38. Koller EA, Cross JT, Doraiswamy PM et al. Risperidone-associated diabetes mellitus: a pharmacovigilance study. Pharmacotherapy. 2003; 23:735-44. http://www.ncbi.nlm.nih.gov/pubmed/12820816?dopt=AbstractPlus
39. Food and Drug Administration. Information for Healthcare Professionals: Conventional antipsychotics. Rockville, MD; 2008 Jun 16. From the FDA website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm124830.htm
40. Ananth J, Johnson KM, Levander EM et al. Diabetic ketoacidosis, neuroleptic malignant syndrome, and myocardial infarction in a patient taking risperidone and lithium carbonate. J Clin Psychiatry. 2004; 65:724. http://www.ncbi.nlm.nih.gov/pubmed/15163265?dopt=AbstractPlus
41. Torrey EF, Swalwell CI. Fatal olanzapine-induced ketoacidosis. Am J Psychiatry. 2003; 160:2241. http://www.ncbi.nlm.nih.gov/pubmed/14638601?dopt=AbstractPlus
42. Wehring HJ, Kelly DL, Love RC et al. Deaths from diabetic ketoacidosis after long-term clozapine treatment. Am J Psychiatry. 2003; 160:2241-2. http://www.ncbi.nlm.nih.gov/pubmed/14638600?dopt=AbstractPlus
43. Koro CE, Fedder DO, L’Italien GJ et al. Assessment of independent effect of olanzapine and risperidone on risk of diabetes among patients with schizophrenia: population based nested case-control study. Br Med J. 2002; 325:243.
44. Citrome LL. Efficacy should drive atypical antipsychotic treatment. Br Med J. 2003; 326:283.
45. Anon. Which atypical antipsychotic for schizophrenia?. Drug Ther Bull. 2004; 42:57-60. http://www.ncbi.nlm.nih.gov/pubmed/15310154?dopt=AbstractPlus
46. Anon. Atypical antipsychotics and hyperglycaemia. Aust Adv Drug React Bull. 2004; 23:11-2.
47. Sussman N. The implications of weight changes with antipsychotic treatment. J Clin Psychopharmacol. 2003; 23 (Suppl 1):S21-6.
48. Gianfrancesco F, Grogg A, Mahmoud R et al. Differential effects of antipsychotic agents on the risk of development of type 2 diabetes mellitus in patients with mood disorders. Clin Ther. 2003; 25:1150-71. http://www.ncbi.nlm.nih.gov/pubmed/12809963?dopt=AbstractPlus
49. Bushe C, Leonard B. Association between atypical antipsychotic agents and type 2 diabetes: review of prospective clinical data. Br J Psychiatry Suppl. 2004; 47:S87-93. http://www.ncbi.nlm.nih.gov/pubmed/15056600?dopt=AbstractPlus
50. Cavazzoni P, Mukhopadhyay N, Carlson C et al. Retrospective analysis of risk factors in patients with treatment-emergent diabetes during clinical trials of antipsychotic medications. Br J Psychiatry Suppl. 2004; 47:s94-101. http://www.ncbi.nlm.nih.gov/pubmed/15056601?dopt=AbstractPlus
51. Gianfrancesco FD, Grogg AL, Mahmoud RA et al. Differential effects of risperidone, olanzapine, clozapine, and conventional antipsychotics on type 2 diabetes: findings from a large health plan database. J Clin Psychiatry. 2002; 63:920-30. http://www.ncbi.nlm.nih.gov/pubmed/12416602?dopt=AbstractPlus
52. Etminan M, Streiner DL, Rochon PA. Exploring the association between atypical neuroleptic agents and diabetes mellitus in older adults. Pharmacotherapy. 2003; 23:1411-15. http://www.ncbi.nlm.nih.gov/pubmed/14620387?dopt=AbstractPlus
53. Leslie DL, Rosenheck RA. Incidence of newly diagnosed diabetes attributable to atypical antipsychotic medications. Am J Psychiatry. 2004; 161:1709-11. http://www.ncbi.nlm.nih.gov/pubmed/15337666?dopt=AbstractPlus
54. Sernyak MJ, Leslie DL, Alarcon RD et al. Association of diabetes mellitus with use of atypical neuroleptics in the treatment of schizophrenia. Am J Psychiatry. 2002; 159:561-6. http://www.ncbi.nlm.nih.gov/pubmed/11925293?dopt=AbstractPlus
55. Geller WK, MacFadden W. Diabetes and atypical neuroleptics. Am J Psychiatry. 2003; 160:388. http://www.ncbi.nlm.nih.gov/pubmed/12562601?dopt=AbstractPlus
56. Gianfrancesco FD. Diabetes and atypical neuroleptics. Am J Psychiatry. 2003; 160:388-9; author reply 389. http://www.ncbi.nlm.nih.gov/pubmed/12562599?dopt=AbstractPlus
57. Lamberti JS, Crilly JF, Maharaj K. Prevalence of diabetes mellitus among outpatients with severe mental disorders receiving atypical antipsychotic drugs. J Clin Psychiatry. 2004; 65:702-6. http://www.ncbi.nlm.nih.gov/pubmed/15163259?dopt=AbstractPlus
58. Lee DW, Fowler RB. Olanzapine/risperidone and diabetes risk. J Clin Psychiatry. 2003; 64:847-8; author reply 848. http://www.ncbi.nlm.nih.gov/pubmed/12934988?dopt=AbstractPlus
59. Reviewer comments (personal observations).
60. AstraZeneca. Wayne, PA: Personal communication.
61. Eli Lilly and Company. Indianapolis, IN: Personal communication.
62. Novartis Pharmaceuticals Corporation. East Hanover, NJ: Personal communication.
63. Janssen Pharmaceuticals. Titusville, NJ: Personal communication.
64. Citrome LL. The increase in risk of diabetes mellitus from exposure to second generation antipsychotic agents. Drugs Today (Barc). 2004; 40:445-64. http://www.ncbi.nlm.nih.gov/pubmed/15319799?dopt=AbstractPlus
65. Citrome L, Jaffe A, Levine J et al. Relationship between antipsychotic medication treatment and new cases of diabetes among psychiatric inpatients. Psychiatr Serv. 2004; 55:1006–13. http://www.ncbi.nlm.nih.gov/pubmed/15345760?dopt=AbstractPlus
66. McIntyre R, Aplhs L, Cohen et al. Long-term double-blind extension studies of asenapine vs. olanzapine in patients with bipolar mania. Schizophren Res. 2008; 98:3–199.
67. Food and Drug Administration. Patient information sheet: aripiprazole (marketed as Abilify). 2006 Sep 6.
68. American Psychiatric Association. DSM-IV: diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994:273-86.
69. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry. 2002; 159(4 Suppl):1-50.
70. Volavka J, Citrome L. Oral antipsychotics for the treatment of schizophrenia: heterogeneity in efficacy and tolerability should drive decision-making. Expert Opin Pharmacother. 2009; 10:1917-28. http://www.ncbi.nlm.nih.gov/pubmed/19558339?dopt=AbstractPlus
71. Lieberman JA. Atypical antipsychotic drugs as a first-line treatment of schizophrenia: a rationale and hypothesis. J Clin Psychiatry. 1996; 57(Suppl 11):68-71. http://www.ncbi.nlm.nih.gov/pubmed/8941173?dopt=AbstractPlus
72. Lahti AC, Tamminga CA. Recent developments in the neuropharmacology of schizophrenia. Am J Health-Syst Pharm. 1995; 52(Suppl 1):S5-8. http://www.ncbi.nlm.nih.gov/pubmed/7749964?dopt=AbstractPlus
73. Food and Drug Administration. Public health advisory: deaths with antipsychotics in elderly patients with behavioral disturbances. Rockville, MD; 2005 Apr 11. From the FDA website. http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/DrugSafetyInformationforHeathcareProfessionals/PublicHealthAdvisories/ucm053171.htm
74. McIntyre RS. Pharmacology and efficacy of asenapine for manic and mixed states in adults with bipolar disorder. Expert Rev Neurother. 2010; 10:645-9. http://www.ncbi.nlm.nih.gov/pubmed/20420486?dopt=AbstractPlus
75. Banerjee S. The use of antipsychotic medication for people with dementia: time for action. A report for the Minister of State for Care Services. United Kingdom Department of Health. From the website. https://www.gov.uk/government/organisations/department-of-health-and-social-care
76. Ortho-McNeil-Janssen Pharmaceuticals. Invega (paliperidone) extended-release tablets prescribing information. Titusville, NJ; 2009 Jul.
77. Stöllberger C, Huber JO, Finsterer J. Antipsychotic drugs and QT prolongation. Int Clin Psychopharmacol. 2005; 20:243-51. http://www.ncbi.nlm.nih.gov/pubmed/16096514?dopt=AbstractPlus
78. Qureshi SU, Rubin E. Risperidone- and aripiprazole-induced leukopenia: a case report. Prim Care Companion J Clin Psychiatry. 2008; 10:482-3. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=2644464&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/19287562?dopt=AbstractPlus
79. Lundbeck Inc. Xenazine (tetrabenazine) tablets prescribing information. Deerfield, IL; 2009 Sep.
80. Meltzer HY, Dritselis A, Yasothan U et al. Asenapine. Nat Rev Drug Discov. 2009; 8:843-4. http://www.ncbi.nlm.nih.gov/pubmed/19876039?dopt=AbstractPlus
81. Merck. Whitehouse Station, NJ; Personal communication.
82. Kane JM, Cohen M, Zhao J et al. Efficacy and safety of asenapine in a placebo- and haloperidol-controlled trial in patients with acute exacerbation of schizophrenia. J Clin Psychopharmacol. 2010; 30:106–15. http://www.ncbi.nlm.nih.gov/pubmed/20520283?dopt=AbstractPlus
83. McIntyre RS, Cohen M, Zhao J et al. Asenapine in the treatment of acute mania in bipolar I disorder: a randomized, double-blind, placebo-controlled trial. J Affect Disord. 2010; 122:27-38. http://www.ncbi.nlm.nih.gov/pubmed/20096936?dopt=AbstractPlus
84. Schoemaker J, Naber D, Vrijland P et al. Long-term assessment of asenapine vs. olanzapine in patients with schizophrenia or schizoaffective disorder. Pharmacopsychiatry. 2010 Mar 4; :[epub ahead of print].
85. Shahid M, Walker GB, Zorn SH et al. Asenapine: a novel psychopharmacologic agent with a unique human receptor signature. J Psychopharmacol. 2009; 23:65-73. http://www.ncbi.nlm.nih.gov/pubmed/18308814?dopt=AbstractPlus
86. McIntyre RS, Cohen M, Zhao J et al. Asenapine for long-term treatment of bipolar disorder: a double-blind 40-week extension study. J Affect Disord. 2010; 126:358-65. http://www.ncbi.nlm.nih.gov/pubmed/20537396?dopt=AbstractPlus
87. Mackle M, Snow-Adami L, Zhao J, Szegedi A, Panagides J. Double-blind, placebo-controlled trial of asenapine in prevention of relapse after long-term treatment of schizophrenia. Eur Neuropsychopharmacol 2009;19 (suppl 3):S543.
88. Reviewer comments (personal observations) on Asenapine Maleate 28:16.08.04.
89. Citrome L. Asenapine for schizophrenia and bipolar disorder: a review of the efficacy and safety profile for this newly approved sublingually absorbed second-generation antipsychotic. Int J Clin Pract. 2009; 63:1762-84. http://www.ncbi.nlm.nih.gov/pubmed/19840150?dopt=AbstractPlus
90. Sexson WR, Barak Y. Withdrawal emergent syndrome in an infant associated with maternal haloperidol therapy. J Perinatol. 1989; 9:170-2. http://www.ncbi.nlm.nih.gov/pubmed/2738729?dopt=AbstractPlus
91. Coppola D, Russo LJ, Kwarta RF Jr. et al. Evaluating the postmarketing experience of risperidone use during pregnancy: pregnancy and neonatal outcomes. Drug Saf. 2007; 30:247-64. http://www.ncbi.nlm.nih.gov/pubmed/17343431?dopt=AbstractPlus
92. US Food and Drug Administration. FDA drug safety communication: Antipsychotic drug labels updated in use during pregnancy and risk of abnormal muscle movements and withdrawal symptoms in newborns.. Rockville, MD; 2011 Feb 22. From the FDA website:. http://www.fda.gov/Drugs/DrugSafety/ucm243903.htm
93. Kane JM, Mackle M, Snow-Adami L et al. A randomized placebo-controlled trial of asenapine for the prevention of relapse of schizophrenia after long-term treatment. J Clin Psychiatry. 2011; 72:349-55. http://www.ncbi.nlm.nih.gov/pubmed/21367356?dopt=AbstractPlus
94. McIntyre RS. Asenapine: a review of acute and extension phase data in bipolar disorder. CNS Neurosci Ther. 2010; :[epub ahead of print]. http://www.ncbi.nlm.nih.gov/pubmed/20950326?dopt=AbstractPlus
95. Peeters P, Bockbrader H, Spaans E. et al. Asenapine pharmacokinetics in hepatic and renal impairment. Clin Pharmacokinet. 2011; 50:471-81. http://www.ncbi.nlm.nih.gov/pubmed/21651314?dopt=AbstractPlus
96. US Food and Drug Administration. FDA drug safety communication: Serious allergic reactions reported with the use of Saphris (asenapine maleate). Rockville, MD; 2011 Sep 1. From the FDA website. http://www.fda.gov/Drugs/DrugSafety/ucm270243.htm
97. Findling RL, Landbloom RP, Mackle M et al. Safety and Efficacy from an 8 Week Double-Blind Trial and a 26 Week Open-Label Extension of Asenapine in Adolescents with Schizophrenia. J Child Adolesc Psychopharmacol. 2015; 25:384-96. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=4491161&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/26091193?dopt=AbstractPlus
98. Ridout KK, Ridout SJ, Pirnie LF et al. Sudden-onset dystonia in a patient taking asenapine: interaction between ciprofloxacin and asenapine metabolism. Am J Psychiatry. 2015; 172:1162-3. http://www.pubmedcentral.nih.gov/picrender.fcgi?tool=pmcentrez&artid=4877163&blobtype=pdf http://www.ncbi.nlm.nih.gov/pubmed/26575453?dopt=AbstractPlus
99. Landbloom RL, Mackle M, Wu X et al. Asenapine: efficacy and safety of 5 and 10mg bid in a 3-week, randomized, double-blind, placebo-controlled trial in adults with a manic or mixed episode associated with bipolar I disorder. J Affect Dis. 2016; 190:103-10. http://www.ncbi.nlm.nih.gov/pubmed/26496015?dopt=AbstractPlus
100. Findling RL, Landbloom RL, Szegedi A et al. Asenapine for the acute treatment of pediatric manic or mixed episode of bipolar I disorder. J Am Acad Child Adolesc Psychiatry. 2015; 54:1032-41. http://www.ncbi.nlm.nih.gov/pubmed/26598478?dopt=AbstractPlus
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