Children and Adolescents

• Safety and efficacy have not been established

• Children and adolescents using asenapine may need to be monitored more often than adults

Pregnancy

• Risk Category C [some animal studies show adverse effects; no controlled studies in humans]

• There is a risk of abnormal muscle movements and withdrawal symptoms in newborns whose mothers took an antipsychotic during the third trimester; symptoms may include agitation, abnormally increased or decreased muscle tone, tremor, sleepiness, severe difficulty breathing, and difficulty feeding

• Psychotic symptoms may worsen during pregnancy and some form of treatment may be necessary

• Asenapine may be preferable to anticonvulsant mood stabilizers if treatment is required during pregnancy

Breast Feeding

• Unknown if asenapine is secreted in human breast milk, but all psychotropics assumed to be secreted in breast milk

✽ Recommended either to discontinue drug or bottle feed

• Infants of women who choose to breast feed while on asenapine should be monitored for possible adverse effects

ASENAPINE: THE ART OF PSYCHOPHARMACOLOGY

Potential Advantages

• Patients requiring rapid onset of antipsychotic action without dosage titration

Potential Disadvantages

• Patients who are less likely to be adherent

Primary Target Symptoms

• Positive symptoms of psychosis

• Negative symptoms of psychosis

• Cognitive symptoms

• Unstable mood (both depression and mania)

• Aggressive symptoms

Pearls

• Asenapine’s chemical structure is related to the antidepressant mirtazapine and it shares many of the same pharmacologic binding properties of mirtazapine plus many others

• Not approved for depression, but binding properties suggest potential use in treatment-resistant and bipolar depression

• Sublingual administration may require prescribing asenapine to reliable, adherent patients, or those who have someone who can supervise drug administration

• Patients with inadequate responses to atypical antipsychotics may benefit from determination of plasma drug levels and, if low, a dosage increase even beyond the usual prescribing limits

• Patients with inadequate responses to atypical antipsychotics may also benefit from a trial of augmentation with a conventional antipsychotic or switching to a conventional antipsychotic

• However, long-term polypharmacy with a combination of a conventional antipsychotic with an atypical antipsychotic may combine their side effects without clearly augmenting the efficacy of either

• For treatment-resistant patients, especially those with impulsivity, aggression, violence, and self-harm, long-term polypharmacy with 2 atypical antipsychotics or with 1 atypical antipsychotic and 1 conventional antipsychotic may be useful or even necessary while closely monitoring

• In such cases, it may be beneficial to combine 1 depot antipsychotic with 1 oral antipsychotic

• Although a frequent practice by some prescribers, adding 2 conventional antipsychotics together has little rationale and may reduce tolerability without clearly enhancing efficacy

THE ART OF SWITCHING