Asenapine (Saphris)

Second generation antipsychotic (dopamine, serotonin, norepinephrine receptor antagonist (5-HT2, D2, NE alpha-2))

  • Schizophrenia3
  • May help bipolar depression4
  • Mania/mixed2 (10+)

Features

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Handout

Dosing

Mania/mixed (10-20 mg/d), Schizophrenia (10-20 mg/d), Bipolar depression (5-10 mg/d, not much research for this but does prevent BP depression). Do not eat/drink for 10 min after taking it. Dissolves in mouth and has a bad cherry taste. Transdermal version doesn’t help much but adds skin irritation.

Management

Less weight gain, akathisia and metabolic effects than other atypicals. The only atypical that is not lowered by CBZ, but as a 2D6 inhibitor asenapine can raise drug levels of antidepressants and other drugs.

A good all-around antipsychotic with high sedation but low rates of other side effects.

TOLERABILITY: Weight gain, sedation, akathisia, EPS (dystonia, stiffness), anticholinergic.

RISKS: Tardive dyskinesia (25% over 10 years, higher in elderly), metabolic, prolactinemia (can lead to breast cancer, osteopenia, sexual dysfunction), orthostasis (falls), QTc prolongation, temperature imbalance in elderly, NMS (muscle rigidity, fever, tachycardia).

Side Effect Management

EMR Text

Bipolar Mania/Mixed

Asenapine use based on FDA approval in bipolar disorder.

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

Bipolar Depression

Asenapine use based on FDA approval in bipolar disorder, and controlled trials where it treated and prevented bipolar depression (El-Mallakh RS et al, Psychopharmacol Bull. 2020;50(1):8-18; Szegedi A et al, Am J Psychiatry. 2018;175(1):71-79).

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

Schizophrenia

Asenapine use based on FDA approval in schizophrenia.

Antipsychotic side effects, including metabolic, prolactinemia, and TD, reviewed with patient.

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