Switching from Oral Antipsychotics to Asenapine

• With aripiprazole, amisulpride, and paliperidone ER, immediate stop is possible; begin asenapine at middle dose

• With risperidone, ziprasidone, iloperidone, and luasidone: begin asenapine gradually, titrating over at least 2 weeks to allow patients to become tolerant to the sedating effect

* May need to taper clozapine slowly over 4 weeks or longer

Suggested Reading

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. International Journal of Clinical Practice. 2009;63(12):1762–84.

Shahid M, Walker GB, Zorn SH, Wong EH. Asenapine: a novel psychopharmacologic agent with a unique human receptor signature. J Psychopharmacol.2009;23(1):65–73.

Tarazi F, Stahl SM. Iloperidone, asenapine and lurasidone: a primer on their current status. Exp Opin Pharmacother 2012;13(13):1911–22.

ATOMOXETINE

ATOMOXETINE: THERAPEUTICS

Brands

• Strattera

see index for additional brand names

Generic?

Yes

Class

• Selective norepinephrine reuptake inhibitor (NRI)

Commonly Prescribed for

(bold for FDA approved)

• Attention deficit hyperactivity disorder (ADHD) in adults and children over 6

• Treatment-resistant depression

How the Drug Works

• Boosts neurotransmitter norepinephrine/noradrenaline and may also increase dopamine in profrontal cortex

• Blocks norepinephrine reuptake pumps, also known as norepinephrine transporters

• Presumably this increases noradrenergic neurotransmission

• Since dopamine is inactivated by norepinephrine reuptake in frontal cortex, which largely lacks dopamine transporters, atomoxetine can also increase dopamine neurotransmission in this part of the brain

How Long Until It Works

✽ Onset of therapeutic actions in ADHD can be seen as early as the first day of dosing

• Therapeutic actions may continue to improve for 8–12 weeks

• If it is not working within 6–8 weeks, it may not work at all

If It Works

• The goal of treatment of ADHD is reduction of symptoms of inattentiveness, motor hyperactivity, and/or impulsiveness that disrupt social, school, and/or occupational functioning

• Continue treatment until all symptoms are under control or improvement is stable and then continue treatment indefinitely as long as improvement persists

• Reevaluate the need for treatment periodically

• Treatment for ADHD begun in childhood may need to be continued into adolescence and adulthood if continued benefit is documented

If It Doesn’t Work

• Consider adjusting dose or switching to another agent

• Consider behavioral therapy

• Consider the presence of noncompliance and counsel patient and parents

• Consider evaluation for another diagnosis or for a comorbid condition (e.g., bipolar disorder, substance abuse, medical illness, etc.)

• Some patients may experience apparent lack of consistent efficacy due to activation of latent or underlying bipolar disorder, and require atomoxetine discontinuation and a switch to a mood stabilizer

Best Augmenting Combos for Partial Response or Treatment Resistance

✽ Best to attempt other monotherapies prior to augmenting

• SSRIs, SNRIs, or mirtazapine for treatment-resistant depression (use combinations of antidepressants with atomoxetine with caution as this may theoretically activate bipolar disorder and suicidal ideation)

• Mood stabilizers or atypical antipsychotics for comorbid bipolar disorder

• For the expert, can combine with modafinil, methylphenidate, or amphetamine for ADHD

Tests

• None recommended for healthy patients

• May be prudent to monitor blood pressure and pulse when initiating treatment and until dosage increments have stabilized