What is the recommended dosage and treatment approach for Invega (paliperidone) in schizophrenia?

Paliperidone (Invega) Dosing and Treatment Approach for Schizophrenia

The recommended dose of paliperidone extended-release (ER) for adults with schizophrenia is 6 mg administered once daily, with a dosage range of 3-12 mg/day based on clinical response and tolerability. 1

Initial Dosing and Titration

• Adults:

  • Starting dose: 6 mg once daily (no initial titration required)
  • Dose range: 3-12 mg/day
  • Maximum recommended dose: 12 mg/day 1

• Adolescents (12-17 years):

  • Starting dose: 3 mg once daily
  • Dose increases should occur at increments of 3 mg/day at intervals of more than 5 days
  • Higher doses showed no clear efficacy enhancement but increased adverse events 1

Dose Adjustment Considerations

• Dose increases above 6 mg/day should:

  • Only occur after clinical reassessment
  • Be made at intervals of more than 5 days
  • Be in increments of 3 mg/day 1

• For patients with renal impairment:

  • Mild impairment (CrCl ≥50 to <80 mL/min): Initial dose 3 mg once daily, maximum 6 mg once daily
  • Moderate to severe impairment (CrCl ≥10 to <50 mL/min): Dose must be individualized 1

Administration Guidelines

• Can be taken with or without food
• Must be swallowed whole with liquids
• Tablets should not be chewed, divided, or crushed 1

Treatment Duration and Monitoring

• Paliperidone ER has been shown effective in delaying relapse in patients stabilized for 6 weeks 1
• The American Psychiatric Association (APA) recommends that patients with schizophrenia whose symptoms have improved continue antipsychotic medication treatment 2
• Prescribe at the lowest effective dose for maintaining clinical stability
• Periodically reevaluate the long-term usefulness of the drug 1

Efficacy and Clinical Response

• Significant improvement in symptoms can be seen after 4 days of treatment in some patients 3
• Effective against both positive and negative symptoms of schizophrenia 3
• The OROS® delivery system allows for once-daily dosing with more stable serum concentration 4

Side Effect Management

• Common adverse events include:

  • Extrapyramidal symptoms (EPS)
  • Tachycardia
  • Somnolence 4

• EPS management options include:

  • Lowering the dosage
  • Switching to another antipsychotic
  • Adding anticholinergic medication for parkinsonism 2
  • Adding benzodiazepine or beta-blocker for akathisia 2

• Monitor for:

  • Increased prolactin levels (common with paliperidone) 4, 3
  • QTc interval prolongation 4
  • Weight gain (clinically significant in 15% of patients in long-term treatment) 3

Treatment Resistance

• APA recommends clozapine for treatment-resistant schizophrenia (failure of two adequate antipsychotic trials) 2
• Consider clozapine if risk for suicide attempts or suicide remains substantial despite other treatments 2

Comprehensive Treatment Approach

• Combine pharmacotherapy with psychosocial interventions:
  • Cognitive-behavioral therapy for psychosis (CBTp) 2
  • Psychoeducation 2
  • Supported employment services 2
  • Family interventions for patients with ongoing family contact 2

Common Pitfalls to Avoid

1. Inadequate dosing or premature dose increases
2. Overlooking adherence issues that may lead to apparent treatment resistance 5
3. Ignoring side effects that can lead to medication discontinuation 5
4. Failure to consider concomitant use with risperidone (additive paliperidone exposure) 1
5. Not adjusting doses for patients with renal impairment

Paliperidone ER offers a convenient once-daily dosing option with a straightforward dosing regimen that doesn't require initial titration for adults, making it a valuable treatment option for patients with schizophrenia.