Effect of absorption site on the pharmacokinetics of sublingual asenapine in healthy male subjects

Optimisation of pharmacotherapy in psychiatry through therapeutic drug monitoring, molecular brain imaging and pharmacogenetic tests: Focus on antipsychotics

BACKGROUND

For psychotic disorders (i.e. schizophrenia), pharmacotherapy plays a key role in controlling acute and long-term symptoms. To find the optimal individual dose and dosage strategy, specialised tools are used. Three tools have been proven useful to personalise drug treatments: therapeutic drug monitoring (TDM) of drug levels, pharmacogenetic testing (PG), and molecular neuroimaging.

METHODS

In these Guidelines, we provide an in-depth review of pharmacokinetics, pharmacodynamics, and pharmacogenetics for 45 antipsychotics. Over 30 international experts in psychiatry selected studies that have measured drug concentrations in the blood (TDM), gene polymorphisms of enzymes involved in drug metabolism, or receptor/transporter occupancies in the brain (positron emission tomography (PET)).

RESULTS

Study results strongly support the use of TDM and the cytochrome P450 (CYP) genotyping and/or phenotyping to guide drug therapies. Evidence-based target ranges are available for titrating drug doses that are often supported by PET findings.

CONCLUSION

All three tools discussed in these Guidelines are essential for drug treatment. TDM goes well beyond typical indications such as unclear compliance and polypharmacy. Despite its enormous potential to optimise treatment effects, minimise side effects and ultimately reduce the global burden of diseases, personalised drug treatment has not yet become the standard of care in psychiatry.

Satisfaction Survey on Antipsychotic Formulations by Schizophrenia Patients in Japan

Objective

Methods

Results

Conclusion

Determination of Asenapine Maleate in Pharmaceutical and Biological Matrices: A Critical Review of Analytical Techniques over the Past Decade

Asenapine maleate is a second-generation atypical antipsychotic agent used in the treatment of schizophrenia, a neuropsychiatric disorder. It is available as a fast-dissolving sublingual tablet to avoid extensive first-pass metabolism with higher bioavailability as compared to oral formulations. Although, the established therapeutic solutions do not sufficiently satisfy the patient's safety and efficacy needs. Thus, the core research emphasis is to investigate strategies to produce novel formulations with enhanced safety and efficacy. This necessitates the development of robust, precise, and accurate methods for quantification of asenapine maleate in different sample matrices. Given the foregoing information, the current analysis concentrates on the different analytical techniques used to assess asenapine maleate in bulk, pharmaceutical formulations, and biological specimens. Reverse-phase HPLC coupled with UV detection is a majorly (nearly 50% of papers investigated) used technique for the estimation of asenapine maleate in formulations. On the other hand, for its quantification in the biological matrix, hyphenated techniques using mass spectrometry are widely used. This critical review reveals different analytical methodologies, including spectrophotometric, chromatographic, capillary electrophoresis techniques reported from 2011 to 2020, for the measurement of asenapine maleate in various sample matrices. The information presented in this review would be useful in future research for robust analytical method development for asenapine maleate utilizing a more scientific and risk-based approach. Also, it would aid to minimize analytical failure as well as method fine-tuning throughout the product life cycle. Further, this review may also direct scientists toward the development of methodologies for green research.

Asenapine: an atypical antipsychotic with atypical formulations

Asenapine is a second-generation (atypical) antipsychotic medication not available in a pill that can be swallowed; rather, it is commercialized in sublingual and transdermal formulations. This is a consequence of extensive first-pass metabolism if ingested. The sublingual formulation is approved in many jurisdictions for the treatment of schizophrenia and manic or mixed episodes associated with bipolar I disorder and is available generically. The efficacy profile is well characterized in a number of clinical trials, including an off-label use for the management of agitation. Obstacles to its use include food and drink restrictions, twice-daily dosing and adverse effects such as dysgeusia (distorted, altered, or unpleasant taste) and oral hypoesthesia (numbness). Transdermal asenapine was approved by the US Food and Drug Administration in 2019 for the treatment of schizophrenia in adults. Efficacy was established in a registrational study examining acutely ill inpatients with schizophrenia. The patch needs to changed once daily. Obstacles to its use include the potential for skin reactions such as erythema and pruritis, and being a branded product, it is more costly than other options. This is a narrative review of the chemistry and pharmacokinetics/pharmacodynamics of asenapine, as well as summarizing the efficacy and tolerability of both sublingual and transdermal asenapine, and its possible place in treatment.

Treatment Continuation of Asenapine or Olanzapine in Japanese Schizophrenia Patients: A Propensity Score Matched Study

OBJECTIVE

Asenapine is a second-generation antipsychotic agent that is classified as a multi-acting receptor-targeted antipsychotic and is similar to olanzapine. Our study aimed to compare the treatment continuation rate and reason for discontinuation of asenapine or olanzapine in schizophrenia using real-world data.

METHODS

This design was a retrospective study. The primary endpoint was Kaplan-Meier estimates of the continuation rate at six months, with the propensity score method applied to adjust for potential confounders.

RESULTS

A total of 95 patients were analyzed in this study (asenapine, n = 46; olanzapine, n = 49). Matched data were adjusted to consider six covariates (age, sex, chlorpromazine equivalent, diazepam equivalent, history of clozapine use, and history of modified electro convulsive therapy). The continuation rate at six months was 27.3% (95% CI, 15.6-47.6) in the asenapine group and 50.8% (95% CI, 34.3-75.3) in the olanzapine group (hazard ratio, 0.41; 95% CI, 0.21-0.82; P = 0.0088 by the Log rank test) in matched data. Cases of discontinuation because of the lack of efficacy were almost as frequent for asenapine (13.0%) as for olanzapine (10.2%). Discontinuation due to bitter taste (6.5%) and burden of the dosing method (6.5%) were observed only with asenapine, whereas anticholinergic side effects such as dry mouth (4.1%) and constipation (2.0%) were observed only with olanzapine.

CONCLUSION

The low continuation rate of asenapine in real-world data may be related to specific factors such as bitter taste and burden of the dosing method.

Pharmacokinetics of a Novel Sildenafil Orodispersible Film Administered by the Supralingual and the Sublingual Route to Healthy Men

Background

Sildenafil was the first selective drug available on the market as oral therapy for erectile dysfunction (ED). A novel sildenafil orodispersible film (ODF) for ED treatment, containing sildenafil citrate, has recently been marketed.

Objectives

Study objective was to investigate sildenafil bioavailability of the novel ODF formulation after sublingual and supralingual administration.

Methods

In this randomised, two-way cross-over study, 12 healthy male volunteers received a single 50 mg sildenafil dose by the sublingual and supralingual administration routes. Plasma sildenafil was determined up to 12 h post-dose. Peak concentration (C_max) and area under concentration-time curve (AUC_0–t) were calculated and compared between the two administration routes by analysis of variance (ANOVA).

Results

Sublingual and supralingual administration can be claimed equivalent regarding the extent of sildenafil exposure since AUC_0–t 90 % CIs corresponded to 94.90–110.58% and were within the pre-specified acceptance range. C_max 90% CIs (79.92–125.57%) were only slightly outside the 80.00–125.00% limits, due to the small sample size, while the time to achieve C_max did not differ between treatments (p = 0.9277). Rate of exposure of the two administration routes was therefore similar. Reported treatment-related adverse events were mild to moderate headache (33.3% of subjects) and vomiting (8.3%).

Conclusions

In healthy men, sublingual and supralingual administration of sildenafil ODF resulted in a remarkably similar pharmacokinetic profile and confirmed the safety of both study treatments. The recently marketed sildenafil ODF, administered by both investigated routes, can provide a valuable alternative to the marketed solid oral forms (tablets) in ED treatment.

A Review of Asenapine in the Treatment of Bipolar Disorder

Bipolar disorder places a significant burden on the affected individuals, their family, healthcare systems and the overall economy. More treatment options are needed, especially those with better efficacy and tolerability. Asenapine is a second-generation antipsychotic approved in Europe (brand name Sycrest^®) for the treatment of moderate-to-severe manic episodes associated with bipolar I disorder in adults, and in the US (brand name Saphris^®) for the treatment of manic or mixed episodes of bipolar I disorder in adults and children aged 10-17 years. It is the antagonistic activity at the D₂ receptor that is likely responsible for the antimanic properties of asenapine. Clinical trials have demonstrated that asenapine mono- and add-on therapy is effective in the short- and long-term treatment of mania associated with bipolar I disorder in adult and paediatric patients. In addition, post hoc and pooled data analyses have shown that asenapine is effective in reducing clinically significant depressive symptoms in patients with bipolar I disorder. The most common adverse events associated with asenapine are somnolence, dizziness, extrapyramidal symptoms, increased bodyweight and oral hypoesthesia. However, the incidence of these events, particularly weight gain, is generally lower than with olanzapine. In one study, asenapine has been shown to improve health-related quality of life. Economic analyses indicate that the use of asenapine can, over time, lead to a reduction in the costs of treatment.

Asenapine augmentation in bipolar disorders: a case series

Asenapine, a novel second‐generation antipsychotic is effective in acute treatment of bipolar I disorder patients in combination with mood stabilizers even in resistant cases. Although there is no evidence for asenapine's efficacy to be superior to currently available agents, asenapine's favorable weight and metabolic profile are of clinical interest.

An ulcerated mouth lesion following one dose of sublingual asenapine

Purpose

To report the first descriptive case of a mouth lesion following one dose of sublingually administered asenapine.

Summary

Asenapine is a second-generation antipsychotic, approved in the United States in August 2009, for the treatment of schizophrenia and acute mania associated with bipolar disorder. It is administered as a sublingual tablet to be taken twice daily. Although the mechanism of action has not been fully elucidated, it is thought to be mediated through a combination of antagonist activity at the dopamine and serotonin 5-HT2A receptors. Sublingual bioavailability is estimated at 35% and is highly plasma protein bound (95%). Oral administration results in low bioavailability (< 2%) due to extensive first-pass metabolism. Adverse tissue reactions identified by the manufacturer include mouth ulcers, blisters, and peeling/sloughing of the contact area. In one manufacturer-sponsored trial, oral paresthesia events were reported for the following administration routes: sublingual (75.8%), supralingual (55.9%), and buccal (45.7%).

Case Report

A 35-year-old patient diagnosed with schizophrenia and swallowing problems was on a regimen that included liquid haloperidol via oral syringe. Adherence was problematic and psychotic symptoms were poorly controlled. The patient was prescribed asenapine 5-mg sublingual tablets to be dissolved under the tongue twice daily. Following the first dose, the patient developed an extremely painful ulcerated lip lesion and refused additional doses. The Naranjo Probability Scale was applied and indicated a probable reaction (7 of 12).

Conclusions

In our patient, the adverse event occurred following one dose. Rechallenge was not attempted. Primary care providers may not be fully aware of the potential severity for this medication-related effect. Based on findings from the manufacturer, clinicians are encouraged to counsel patients and conduct follow-up to determine whether any adverse oral effects were experienced that might have an impact on medication adherence.

Asenapine for bipolar disorder

Asenapine (Saphris(®)) is an atypical antipsychotic drug which has been approved by the US Food and Drug Administration for the treatment of schizophrenia in adults, as well as the treatment of acute manic or mixed episodes of bipolar I in both adult and pediatric populations. Asenapine is a tetracyclic drug with antidopaminergic and antiserotonergic activity with a unique sublingual route of administration. In this review, we examine and summarize the available literature on the safety, efficacy, and tolerability of asenapine in the treatment of bipolar disorder (BD). Data from randomized, double-blind trials comparing asenapine to placebo or olanzapine in the treatment of acute manic or mixed episodes showed asenapine to be an effective monotherapy treatment in clinical settings; asenapine outperformed placebo and showed noninferior performance to olanzapine based on improvement in the Young Mania Rating Scale scores. There are limited data available on the use of asenapine in the treatment of depressive symptoms of BD, or in the maintenance phase of BD. The available data are inconclusive, suggesting the need for more robust data from prospective trials in these clinical domains. The most commonly reported adverse effect associated with use of asenapine is somnolence. However, the somnolence associated with asenapine use did not cause significant rates of discontinuation. While asenapine was associated with weight gain when compared to placebo, it appeared to be modest when compared to other atypical antipsychotics, and its propensity to cause increases in hemoglobin A1c or serum lipid levels appeared to be similarly modest. Asenapine does not appear to cause any clinically significant QTc prolongation. The most commonly reported extra-pyramidal symptom associated with asenapine was akathisia. Overall, asenapine appears to be a relatively well-tolerated atypical antipsychotic, effective in the treatment of acute manic and mixed episodes of BD.

New approaches for the management of bipolar disorder: role of sublingual asenapine in the treatment of mania

Bipolar disorder is a prevalent disorder that tends to become progressive without treatment and with inadequate treatment. Second generation (atypical) antipsychotic drugs have increasingly been used as adjunctive treatment or monotherapy for mania, but they have the potential for significant adverse effects and their role in maintenance treatment remains unclear. Asenapine is a new atypical antipsychotic medication formulated in a sublingual preparation that has been studied for mania but not maintenance therapy. Evidence indicating efficacy, adverse effects, and potential benefits and drawbacks of using asenapine in the treatment of bipolar disorder based on currently available published data are summarized.

Role of sublingual asenapine in treatment of schizophrenia

Asenapine tablets are a new option for the treatment of schizophrenia. Sublingual administration is essential because bioavailability if ingested is less than 2%. Efficacy is supported by acute and long-term randomized controlled studies conducted by the manufacturer, with asenapine 5 mg twice daily evidencing superiority over placebo in six-week studies of acute schizophrenia, and flexibly-dosed asenapine (modal dose 10 mg twice daily) superior to placebo in a 26-week maintenance of response study. Tolerability advantages over some second-generation antipsychotics, such as olanzapine, include a relatively favorable weight and metabolic profile, as demonstrated in a 52-week randomized, head-to-head, double-blind clinical trial. Although dose-related extrapyramidal symptoms and akathisia can be present, the frequency of these effects is lower than that for haloperidol and risperidone. Somnolence may also occur, and appears to be somewhat dose-dependent when examining rates of this among patients receiving asenapine for schizophrenia and bipolar disorder. Prolactin elevation can occur, but at a rate lower than that observed for haloperidol or risperidone. Unique to asenapine is the possibility of oral hypoesthesia, occurring in about 5% of participants in the clinical trials. Obstacles to the use of asenapine are the recommendations for twice-daily dosing and the need to avoid food or liquids for 10 minutes after administration, although the bioavailability is only minimally reduced if food or liquids are avoided for only two minutes.