Can the dose of Invega Sustenna (paliperidone) be increased from 156 mg?

Maximum Dose of Invega Sustenna (Paliperidone Palmitate)

The maximum approved dose of Invega Sustenna (paliperidone palmitate) is 234 mg (150 mg eq.), which is higher than the 156 mg dose mentioned in the question.

Dosing Information for Invega Sustenna

Invega Sustenna is available in multiple dose strengths, with the following options:

• 39 mg (25 mg eq.)
• 78 mg (50 mg eq.)
• 117 mg (75 mg eq.)
• 156 mg (100 mg eq.)
• 234 mg (150 mg eq.)

Recommended Dosing Protocol

1. Initiation regimen:

   • Day 1: 234 mg (150 mg eq.) administered in the deltoid muscle
   • Day 8: 156 mg (100 mg eq.) administered in the deltoid muscle
   • No oral supplementation is required with this regimen

2. Monthly maintenance dosing:

   • Range: 39-234 mg (25-150 mg eq.)
   • Recommended dose: 117 mg (75 mg eq.)
   • Can be administered in either deltoid or gluteal muscle

Dose Adjustment Considerations

When considering dose increases above 156 mg:

• Dose adjustments should be based on clinical response and tolerability
• Increases should not occur more frequently than every 4 weeks
• If increasing from 156 mg to 234 mg, monitor for:
  • Extrapyramidal symptoms
  • Hyperprolactinemia
  • Sedation
  • Weight gain
  • Potential cardiovascular effects

Special Populations

• Renal impairment: Dose adjustments required for mild renal impairment (CrCl 50-80 mL/min)
• Elderly patients: Same dosage as younger adults with normal renal function, but adjust if age-related decline in renal function occurs

Pharmacokinetic Considerations

The pharmacokinetic profile of paliperidone palmitate is biphasic:

• Initial relatively fast zero-order input allows rapid attainment of therapeutic concentrations
• Subsequent maintained second-stage, first-order input allows for monthly administration

Clinical Implications of Dosing

Higher doses may be associated with:

• Increased risk of adverse effects including tachycardia, hypotension, QT prolongation, and extrapyramidal symptoms 1
• Potentially improved symptom control in patients with inadequate response to lower doses

Conclusion

For patients currently on 156 mg of Invega Sustenna who require dose escalation, the maximum available dose is 234 mg (150 mg eq.) administered monthly. This should be considered only after evaluating the patient's clinical response to the current dose and weighing the potential benefits against increased risk of side effects.