Source: European Medicines Agency (EU) Revision Year: 2022 Publisher: N.V. Organon, Kloosterstraat 6, NL-5349 AB Oss, The Netherlands
Pharmacotherapeutic group: Psycholeptics, antipsychotics
ATC code: N05AH05
The mechanism of action of asenapine is not fully understood. However, based on its receptor pharmacology, it is proposed that the efficacy of asenapine is mediated through a combination of antagonist activity at D2 and 5-HT2A receptors. Actions at other receptors e.g. 5-HT1A, 5-HT1B, 5-HT2C, 5-HT6, 5-HT7, D3, and a2-adrenergic receptors, may also contribute to the clinical effects of asenapine.
Asenapine exhibits high affinity for serotonin 5-HT1A, 5-HT1B, 5-HT2A, 5-HT2B, 5-HT2C, 5-HT5, 5-HT6, and 5-HT7 receptors, dopamine D2, D3, D4, and D1 receptors, α1 and a2-adrenergic receptors, and histamine H1 receptors, and moderate affinity for H2 receptors. In in vitro assays asenapine acts as an antagonist at these receptors. Asenapine has no appreciable affinity for muscarinic cholinergic receptors.
The efficacy of asenapine in the treatment of a DSM-IV manic or mixed episode of bipolar I disorder with or without psychotic features was evaluated in two similarly designed 3-week, randomized, double-blind, flexible-dose, placebo- and active controlled (olanzapine) monotherapy trials involving 488 and 489 patients, respectively. All patients met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) diagnostic criteria for bipolar I disorder, current episode manic (DSM-IV 296.4x), or mixed (DSM-IV 296.6x) and had a Young Mania Rating Scale (Y-MRS) score of >20 at screening and baseline. Patients with rapid cycling were excluded from these studies. Asenapine demonstrated superior efficacy to placebo in the reduction of manic symptoms over 3 weeks. Point estimates [95% CI] for the change from baseline to endpoint in YMRS using LOCF analysis in the two studies were as follows: -11.5 [-13.0, -10.0] for asenapine vs -7.8 [-10.0, -5.6] for placebo and -10.8 [-12.3, -9.3] for asenapine vs -5.5 [-7.5, -3.5] for placebo.
A statistically significant difference between asenapine and placebo was seen as early as day 2.
Patients from the two pivotal 3 week trials were studied for a further 9 weeks an extension trial. Maintenance of effect during the episode after 12 weeks of randomised treatment was demonstrated in this trial.
In one double-blind, fixed-dose, parallel-group, 3-week placebo controlled trial in subjects with bipolar I disorder experiencing an acute manic or mixed episode involving 367 patients of which 126 received placebo, 122 received asenapine 5 mg twice daily (BID), and 119 received asenapine 10 mg BID, the primary efficacy hypothesis was met. Both asenapine doses (5 mg BID and 10 mg BID) were superior to placebo and showed statistically significant improvement in change from baseline in Y-MRS total score at Day 21 compared with placebo. Based upon a LOCF analysis including all patients treated, the difference in least squares (LS) mean change from baseline to Day 21 in the Y-MRS total score between asenapine 5 mg BID and placebo was -3.1 points (95% CI [-5.7, -0.5]; p-value = 0.0183). The difference in LS mean change from baseline to Day 21 in the Y-MRS total score between asenapine 10 mg BID and placebo was -3.0 points (95% CI [-5.6, -0.4]; p-value = 0.0244). A statistically significant difference between asenapine and placebo was seen as early as day 2. In this short-term, fixed-dose controlled trial there was no evidence of added benefit with a 10 mg twice daily dose compared to 5 mg twice daily.
In a 12-week, placebo-controlled trial involving 326 patients with a manic or mixed episode of bipolar I disorder, with or without psychotic features, who were partially non-responsive to lithium or valproate monotherapy for 2 weeks at therapeutic serum levels, the addition of asenapine as adjunctive therapy resulted in superior efficacy to lithium or valproate monotherapy at week 3 (point estimates [95 % CI] for the change from baseline to endpoint in YMRS using LOCF analysis were -10.3 [-11.9, -8.8] for asenapine and -7.9 [-9.4, -6.4] for placebo) and at week 12 (-12.7 [-14.5, -10.9] for asenapine and -9.3 [-11.8, -7.6] for placebo) in the reduction of manic symptoms.
Asenapine is not indicated for the treatment of children and adolescent patients below 18 years (see section 4.2).
The safety and efficacy of Sycrest was evaluated in 403 paediatric patients with bipolar I disorder who participated in a single, 3-week, placebo-controlled, double-blind trial, of whom 302 patients received Sycrest at fixed doses ranging from 2.5 mg to 10 mg twice daily. Study results showed statistically significant superiority for all three Sycrest doses in improving the Young Mania Rating Scale (YMRS) total score as measured by the change from baseline to Day 21, as compared with placebo. Long term efficacy could not be established in a 50-week, uncontrolled, open-label extension trial. The clinically relevant adverse reactions identified in the paediatric trials were generally similar to those observed in the adult trials. However, adverse effects of treatment on weight gain and on plasma lipid profile appeared to be greater than effects observed in the adult trials.
Efficacy of Sycrest was not demonstrated in an 8-week, placebo-controlled, double-blind, randomized, fixed-dose trial in 306 adolescent patients aged 12-17 years with schizophrenia at doses of 2.5 and 5 mg twice daily.
Paediatric studies with Sycrest were performed using flavoured sublingual tablets. The European Medicines Agency has deferred the obligation to submit the results of studies with Sycrest in one or more subsets of the paediatric population in bipolar I disorder (see section 4.2 for information on paediatric use).
Following sublingual administration, asenapine is rapidly absorbed with peak plasma concentrations occurring within 0.5 to 1.5 hours. The absolute bioavailability of sublingual asenapine at 5 mg is 35%. The absolute bioavailability of asenapine when swallowed is low (<2% with an oral tablet formulation). The intake of water several (2 or 5) minutes after asenapine administration resulted in decreased (19% and 10%, respectively) asenapine exposure. Therefore, eating and drinking should be avoided for 10 minutes after administration (see section 4.2).
Asenapine is rapidly distributed and has a large volume of distribution (approximately 20-25 L/kg), indicating extensive extravascular distribution. Asenapine is highly bound (95%) to plasma proteins, including albumin and a1-acid glycoprotein.
Asenapine is extensively metabolized. Direct glucuronidation (mediated by UGT1A4) and cytochrome P450 (primarily CYP1A2, with contributions of 2D6 and 3A4) mediated oxidation and demethylation are the primary metabolic pathways for asenapine. In an in vivo study in humans with radio-labelled asenapine, the predominant drug-related entity in plasma was asenapine N+-glucuronide; others included N-desmethylasenapine, N-desmethylasenapine N-carbamoyl glucuronide, and unchanged asenapine in smaller amounts. Sycrest activity is primarily due to the parent compound.
Asenapine is a weak inhibitor of CYP2D6. Asenapine does not cause induction of CYP1A2 or CYP3A4 activities in cultured human hepatocytes. Co-administration of asenapine with known inhibitors, inducers or substrates of these metabolic pathways has been studied in a number of drug-drug interaction studies (see section 4.5).
Asenapine is a high clearance compound, with a clearance after intravenous administration of 52 L/h. In a mass balance study, the majority of the radioactive dose was recovered in urine (about 50%) and faeces (about 40%), with only a small amount excreted in faeces (5-16%) as unchanged compound.
Following an initial more rapid distribution phase, the terminal half-life of asenapine is approximately 24 h.
Increasing the dose from 5 to 10 mg twice daily (a two-fold increase) results in less than linear (1.7 times) increases in both the extent of exposure and maximum concentration. The less than proportional increase of Cmax and AUC with dose may be attributed to limitations in the absorption capacity from the oral mucosa following sublingual administration.
During twice-daily dosing, steady-state is attained within 3 days. Overall, steady-state asenapine pharmacokinetics are similar to single-dose pharmacokinetics.
The pharmacokinetics of asenapine were similar among subjects with mild (Child-Pugh A) or moderate (Child-Pugh B) hepatic impairment and subjects with normal hepatic function. In subjects with severe hepatic impairment (Child-Pugh C), a 7-fold increase in asenapine exposure was observed (see section 4.2).
The pharmacokinetics of asenapine following a single dose of 5 mg asenapine were similar among subjects with varying degrees of renal impairment and subjects with normal renal function. There is no experience with asenapine in severe renal impairment patients with a creatinine clearance less than 15 mL/min.
In elderly patients (between 65 and 85 years of age), exposure to asenapine is approximately 30% higher than in younger adults.
In a PK study using unflavoured sublingual tablets, at the 5 mg twice daily dose level, asenapine pharmacokinetics in adolescent patients (12 to 17 years of age, inclusive) are similar to those observed in adults. In adolescents, the 10 mg twice daily dose did not result in increased exposure compared to 5 mg twice daily.
In a second PK study using flavoured sublingual tablets, the 10 mg twice daily dose in a paediatric population (10 to 17 years of age, inclusive) resulted in an approximate dose-proportional increase in asenapine exposure compared to 5 mg twice daily.
A population pharmacokinetic analysis indicated that there is no evidence of gender-related differences in the pharmacokinetics of asenapine.
In a population pharmacokinetic analysis, no clinical relevant effects of race on the pharmacokinetics of asenapine were found.
A population pharmacokinetic analysis indicated that smoking, which induces CYP1A2, has no effect on the clearance of asenapine. In a dedicated study, concomitant smoking during administration of a single 5 mg sublingual dose had no effect on the pharmacokinetics of asenapine.
Non-clinical data reveal no special hazard for humans based on conventional studies of safety pharmacology. Repeat-dose toxicity studies in rat and dog showed mainly dose-limiting pharmacological effects, such as sedation. Furthermore, prolactin-mediated effects on mammary glands and oestrus cycle disturbances were observed. In dogs high oral doses resulted in hepatotoxicity that was not observed after chronic intravenous administration. Asenapine has some affinity to melanin-containing tissues. However, when tested in vitro it was devoid of phototoxicity. In addition, histopathological examination of the eyes from dogs treated chronically with asenapine did not reveal any signs of ocular toxicity, demonstrating the absence of a phototoxic hazard. Asenapine was not genotoxic in a battery of tests. In subcutaneous carcinogenicity studies in rats and mice, no increases in tumour incidences were observed. Effects in non-clinical studies were observed only at exposures considered sufficiently in excess of the maximum human exposure indicating little relevance to clinical use.
Asenapine did not impair fertility in rats and was not teratogenic in rat and rabbit. Embryotoxicity was found in reproduction toxicology studies using rats and rabbits. Asenapine caused mild maternal toxicity and slight retardation of foetal skeletal development. Following oral administration to pregnant rabbits during the period of organogenesis, asenapine adversely affected body weight at the high dose of 15 mg.kg-1 twice daily. At this dose foetal body weight decreased. When asenapine was administered intravenously to pregnant rabbits, no signs of embryotoxicity were observed. In rats, embryofoetal toxicity (increased post-implantation loss, decreased foetal weights, and delayed ossification) was observed following oral or intravenous administration during organogenesis or throughout gestation. Increased neonatal mortality was observed among the offspring of female rats treated during gestation and lactation. From a cross-fostering study it was concluded that asenapine induced peri- and postnatal losses are caused by impairment of the pups rather than altered nursing behaviour of the dams.
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