Restarting Invega Sustenna After Discontinuation
When restarting Invega Sustenna after a treatment gap, you do NOT need oral supplementation if you follow the FDA-approved re-initiation protocols, which vary based on how long the patient has been off the injection 1.
Re-initiation Protocol Based on Time Since Last Injection
The FDA label provides clear, time-based algorithms for restarting 1:
If >6 weeks to ≤6 months since last injection:
- Resume the same dose the patient was previously stabilized on
- Exception: If previously on 234 mg, use 156 mg for first two injections
- Schedule:
- First injection: Deltoid muscle, as soon as possible
- Second injection: Deltoid muscle, 1 week later (same dose)
- Third injection onward: Resume previous maintenance dose, deltoid or gluteal, monthly intervals
- No oral supplementation required
If >6 months since last injection:
- Full re-initiation required (treat as new start):
- Day 1: 234 mg deltoid injection
- Day 8: 156 mg deltoid injection
- Month 2 onward: Resume previous maintenance dose, deltoid or gluteal, monthly
- No oral supplementation required
Key Clinical Considerations
The loading dose strategy eliminates the need for oral bridging. The FDA-approved initiation regimen (234 mg followed by 156 mg one week later, both deltoid) achieves therapeutic levels rapidly without oral supplementation 1. This is supported by population pharmacokinetic modeling demonstrating adequate plasma concentrations with this approach 2, 3.
Common Pitfall to Avoid:
Do not assume oral bridging is necessary when restarting—the deltoid loading doses provide sufficient drug exposure. The package insert explicitly states "no oral supplementation is required" with proper initiation 1.
Special Circumstances:
If switching FROM oral risperidone or paliperidone TO Invega Sustenna:
- Establish tolerability with oral paliperidone or risperidone first if never taken before
- Previous oral antipsychotics can be gradually discontinued at time of first injection 1
- Some evidence suggests bridging may reduce hospitalization in patients on ≥4 mg/day risperidone, though this is not FDA-mandated 4
Caution with concurrent use: Extended coadministration with oral risperidone or paliperidone should be avoided, as paliperidone is risperidone's active metabolite 1.