Can paliperidone (Invega) cause cardiac arrhythmias?

From the FDA Drug Label

Other potential signs and symptoms include those resulting from an exaggeration of paliperidone’s known pharmacological effects, i.e., drowsiness and somnolence, tachycardia and hypotension, and QT prolongation. Torsade de pointes and ventricular fibrillation have been reported in a patient in the setting of overdose.

Cardiovascular monitoring should commence immediately, including continuous electrocardiographic monitoring for possible arrhythmias.

Yes, paliperidone (Invega) can cause cardiac arrhythmias, as evidenced by reports of QT prolongation, torsade de pointes, and ventricular fibrillation in the setting of overdose 1, 1. Key points to consider include:

• QT prolongation: a potential effect of paliperidone that can increase the risk of arrhythmias
• Torsade de pointes and ventricular fibrillation: reported in a patient with paliperidone overdose
• Cardiovascular monitoring: recommended to detect possible arrhythmias in patients taking paliperidone, especially in the setting of overdose

From the Research

Yes, paliperidone can cause arrhythmias, as it has a known risk of QT interval prolongation, which can lead to serious heart rhythm disturbances including torsades de pointes. This antipsychotic medication, available as oral tablets (Invega) and long-acting injections (Invega Sustenna, Invega Trinza, Invega Hafyera), has a dose-dependent risk that may be higher in patients with certain risk factors such as electrolyte abnormalities (particularly low potassium or magnesium), congenital long QT syndrome, heart disease, or when taking other medications that prolong the QT interval 2.

Key Points to Consider

• The mechanism involves paliperidone's blockade of potassium channels in cardiac tissue, which affects cardiac repolarization 3.
• Patients taking paliperidone should be monitored for symptoms like palpitations, dizziness, fainting, or seizures.
• Baseline and periodic ECGs are recommended, especially when using higher doses or in patients with risk factors 4.
• Electrolyte levels should also be monitored and corrected if abnormal.

Management and Prevention

• Removal or correction of precipitants, including discontinuation of culprit drugs and institution of cardiac monitoring, is crucial in managing torsades de pointes or marked QT prolongation 4.
• Electrolyte abnormalities and hypoxia should be corrected, with potassium concentrations maintained in the high normal range.
• Immediate treatment of torsades de pointes is by intravenous administration of magnesium sulphate, terminating prolonged episodes using electrical cardioversion 4.

Clinical Implications

• Clinically, paliperidone is considered to play a more important role in QT prolongation than risperidone 3.
• A case of apparent seizure and atrial fibrillation associated with paliperidone has been reported, highlighting the need for careful monitoring and management of patients on this medication 5.