Molecular mass: 285.77 g/mol  PubChem compound: 163091


Asenapine interacts in the following cases:

Patients with risk factors for QT-prolongation, QT-prolonging medicinal products

Clinically relevant QT prolongation does not appear to be associated with asenapine. Caution should be exercised when asenapine is prescribed in patients with known cardiovascular disease or family history of QT prolongation, and in concomitant use with other medicinal products thought to prolong the QT interval.

Medicinal products that are both substrates and inhibitors for CYP2D6

In vitro studies indicate that asenapine weakly inhibits CYP2D6. Clinical drug interaction studies investigating the effects of CYP2D6 inhibition by asenapine showed the following results:

  • Following co-administration of dextromethorphan and asenapine in healthy subjects, the ratio of dextrorphan/dextromethorphan (DX/DM) as a marker of CYP2D6 activity was measured. Indicative of CYP2D6 inhibition, treatment with asenapine 5 mg twice daily resulted in a fractional decrease in DX/DM ratio to 0.43. In the same study, treatment with paroxetine 20 mg daily decreased the DX/DM ratio to 0.032.
  • In a separate study, co-administration of a single 75 mg dose of imipramine with a single 5 mg dose of asenapine did not affect the plasma concentrations of the metabolite desipramine (a CYP2D6 substrate).
  • Co-administration of a single 20 mg dose of paroxetine (a CYP2D6 substrate and inhibitor) during treatment with 5 mg asenapine twice daily in 15 healthy male subjects resulted in an almost 2-fold increase in paroxetine exposure.

In vivo asenapine appears to be at most a weak inhibitor of CYP2D6. However, asenapine may enhance the inhibitory effects of paroxetine on its own metabolism. Therefore, asenapine should be co-administered cautiously with medicinal products that are both substrates and inhibitors for CYP2D6.

Moderate hepatic impairment

The possibility of elevated asenapine plasma levels cannot be excluded in some patients with moderate hepatic impairment (Child-Pugh B) and caution is advised.

Severe hepatic impairment

In subjects with severe hepatic impairment (Child-Pugh C), a 7-fold increase in asenapine exposure was observed. Thus, asenapine is not recommended in patients with severe hepatic impairment.


Because of its a1-adrenergic antagonism with potential for inducing orthostatic hypotension, asenapine may enhance the effects of certain antihypertensive agents.

Centrally acting medicinal products

Given the primary effects of asenapine on the central nervous system (CNS), caution should be used when it is taken in combination with other centrally acting medicinal products. Patients should be advised to avoid alcohol while taking asenapine.


Asenapine is cleared primarily through direct glucuronidation by UGT1A4 and oxidative metabolism by cytochrome P450 isoenzymes (predominantly CYP1A2). The potential effects of fluvoxamine (CYP1A2 inhibitor) were studied.

During combined administration with a single dose of asenapine 5 mg, fluvoxamine 25 mg twice daily resulted in a 29% increase in asenapine AUC. The full therapeutic dose of fluvoxamine would be expected to produce a greater increase in asenapine plasma concentrations. Therefore, co-administration of asenapine and fluvoxamine should be approached with caution.

Levodopa, dopamine agonists

Asenapine may antagonise the effect of levodopa and dopamine agonists. If this combination is deemed necessary, the lowest effective dose of each treatment should be prescribed.

Conditions that may contribute to an elevation in core body temperature

Disruption of the body’s ability to reduce core body temperature has been attributed to antipsychotic medicines. From the clinical trials, it is concluded that clinically relevant body temperature dysregulation does not appear to be associated with asenapine. Appropriate care is advised when prescribing asenapine for patients who will be experiencing conditions that may contribute to an elevation in core body temperature, e.g. exercising strenuously, exposure to extreme heat, receiving concomitant medicinal products with anticholinergic activity or being subject to dehydration.

Parkinson's disease, dementia with Lewy bodies

Physicians should weigh the risks versus the benefits when prescribing asenapine to patients with Parkinson’s disease or dementia with Lewy Bodies (DLB) since both groups may be at increased risk of neuroleptic malignant syndrome as well as having an increased sensitivity to antipsychotics. Manifestation of this increased sensitivity can include confusion, obtundation, postural instability with frequent falls, in addition to extrapyramidal symptoms.

Cardiovascular disease, cerebrovascular disease, conditions predisposing the patient to hypotension

Asenapine should be used with caution in elderly patients and in patients with known cardiovascular disease (e.g. heart failure, myocardial infarction or ischemia, conduction abnormalities), cerebrovascular disease, or conditions that predispose the patient to hypotension (e.g. dehydration and hypovolemia).

History of seizure disorder, conditions associated with seizures

Asenapine should be used with caution in patients who have a history of seizure disorder or have conditions associated with seizures.


There are no adequate data from the use of asenapine in pregnant women. Asenapine was not teratogenic in animal studies. Maternal and embryo toxic effects were found in animal studies.

Newborn infants exposed to antipsychotics during the third trimester of pregnancy are at risk of adverse reactions including extrapyramidal and/or withdrawal symptoms that may vary in severity and duration following delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, or feeding disorder in newborn infants. Consequently, newborn infants should be monitored carefully.

Asenapine should not be used during pregnancy unless the clinical condition of the woman requires treatment with asenapine and only if the potential benefit outweighs the potential risk to the foetus.

Nursing mothers

Asenapine was excreted in milk of rats during lactation. It is not known whether asenapine or its metabolites are excreted in human milk. Breast-feeding should be discontinued during treatment with asenapine.

Carcinogenesis, mutagenesis and fertility


No impairment of fertility has been observed in nonclinical studies.

Effects on ability to drive and use machines

Asenapine may cause somnolence and sedation. Therefore, patients should be cautioned about driving and using machines until they are reasonably certain that asenapine therapy does not affect them adversely.

Adverse reactions

Summary of safety profile

The most frequently reported adverse drug reactions (ADRs) associated with the use of asenapine in clinical trials were somnolence and anxiety. Serious hypersensitivity reactions have been reported.

Tabulated list of adverse reactions

The incidences of the ADRs associated with asenapine therapy are tabulated below. The table is based on adverse reactions reported during clinical trials and/or post-marketing use.

All ADRs are listed by system organ class and frequency; very common (≥1/10), common (≥1/100 to <1/10), uncommon (≥1/1,000 to <1/100), rare (≥1/10,000 to <1/1,000) and not known (cannot be estimated from the available data). Within each frequency grouping, ADRs are presented in order of decreasing seriousness.

System organ
Common Uncommon Rare Not
Blood and
Immune system
and nutrition
Restless legs
Eye disorders    Accommodation
Bundle branch
Electrocardio-gram QT
thoracic and
Swollen tongue
Oral mucosal
blistering and
poisoning and
and connective
tissue disorders
 Muscle rigidity Rhabdomyolysis 
puerperium and
system and
breast disorders
disorders and
site conditions

* See subsection “Falls” below

Description of selected adverse reactions

Extrapyramidal Symptoms (EPS)

In clinical trials, the incidence of extrapyramidal symptoms in asenapine-treated patients was higher than placebo (15.4% vs 11.0%).

From the short-term (6 weeks) schizophrenia trials there appears to be a dose-response relationship for akathisia in patients treated with asenapine, and for parkinsonism there was an increasing trend with higher doses.

Based on a small pharmacokinetic study, paediatric patients appeared to be more sensitive to dystonia with initial dosing with asenapine when a gradual up-titration schedule was not followed. The incidence of dystonia in paediatric clinical trials using a gradual up-titration was similar to that seen in adult trials.

Weight increase

In the combined short-term and long-term schizophrenia and bipolar mania trials in adults, the mean change in body weight for asenapine was 0.8 kg. The proportion of subjects with clinically significant weight gain (≥7% weight gain from baseline at endpoint) in the short-term schizophrenia trials was 5.3% for asenapine compared to 2.3% for placebo. The proportion of subjects with clinically significant weight gain (≥7% weight gain from baseline at endpoint) in the short-term, flexible-dose bipolar mania trials was 6.5% for asenapine compared to 0.6% for placebo.

In a 3-week, placebo-controlled, randomized, fixed-dose efficacy and safety trial in paediatric patients 10 to 17 years of age with bipolar I disorder, the mean change from baseline to endpoint in weight for placebo and asenapine 2.5 mg, 5 mg, and 10 mg twice daily, was 0.48, 1.72, 1.62, and 1.44 kg, respectively. The proportion of subjects with clinically significant weight gain (≥7% weight gain from baseline at Day 21) was 14.1% for asenapine 2.5 mg twice daily, 8.9% for asenapine 5 mg twice daily, and 9.2% for asenapine 10 mg twice daily, compared to 1.1% for placebo. In the long-term extension trial (50 weeks), a total of 34.8% of subjects experienced clinically significant weight increase (i.e. ≥7% increase in body weight at endpoint). Overall mean (SD) weight gain at study endpoint was 3.5 (5.76) kg.

Orthostatic hypotension

The incidence of orthostatic hypotension in elderly subjects was 4.1% compared to 0.3% in the combined phase ⅔ trial population.


Falls may occur as a result of one or more adverse events such as the following: Somnolence, Orthostatic hypotension, Dizziness, Extrapyramidal symptoms.

Hepatic enzymes

Transient, asymptomatic elevations of hepatic transaminases, alanine transferase (ALT), aspartate transferase (AST) have been seen commonly, especially in early treatment.

Other findings

Cerebrovascular events have been reported in patients treated with asenapine but there is no evidence of any excess incidence over what is expected in adults between 18 and 65 years of age.

Asenapine has anaesthetic properties. Oral hypoaesthesia and oral paraesthesia may occur directly after administration and usually resolves within 1 hour.

There have been post-marketing reports of serious hypersensitivity reactions in patients treated with asenapine, including anaphylactic/anaphylactoid reactions, angioedema, swollen tongue and swollen throat (pharyngeal oedema).

Paediatric population

Asenapine is not indicated for the treatment of children and adolescent patients below 18 years.

The clinically relevant adverse experiences identified in the paediatric bipolar and schizophrenia trials were similar to those observed in adult bipolar and schizophrenia trials.

The most common adverse reactions (≥5% and at least twice the rate of placebo) reported in paediatric patients with bipolar I disorder were somnolence, sedation, dizziness, dysgeusia, hypoaesthesia oral, paraesthesia oral, nausea, increased appetite, fatigue, and weight increased (see Weight increase above).

The most common adverse reactions (proportion of patients ≥5% and at least twice placebo) reported in paediatric patients with schizophrenia were somnolence, sedation, akathisia, dizziness, and hypoaesthesia oral. There was a statistically significant higher incidence of patients with ≥7% weight gain (from baseline to endpoint) compared to placebo (3.1%) for Asenapine 2.5 mg twice daily (9.5%) and asenapine 5 mg twice daily (13.1%).

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