What is the reinitiation schedule for Sustenna (paliperidone) 150mg depot after a missed dose?

Reinitiation Schedule for Missed Paliperidone Palmitate (Sustenna) 150mg Depot Injection

For a missed Sustenna 150mg depot injection from September 5, you should restart with the full initiation schedule of 150mg eq. on day 1 followed by 100mg eq. on day 8, both administered in the deltoid muscle.

Understanding Paliperidone Palmitate (Sustenna)

• Paliperidone palmitate is a long-acting injectable (LAI) antipsychotic with a half-life of 24-49 days, depending on dose 1
• After injection, the drug release starts as early as day 1, reaches maximum plasma concentration at 13 days, and can last up to 126 days 2
• The medication comes in prefilled syringes with multiple dosage strengths and does not require refrigeration 2

Reinitiation Protocol Based on Time Since Last Dose

When more than 6 weeks have passed since the last maintenance dose (which is your case), a complete reinitiation schedule is required:

• Day 1: Administer 150mg equivalent (234mg paliperidone palmitate) in the deltoid muscle 3
• Day 8: Administer 100mg equivalent (156mg paliperidone palmitate) in the deltoid muscle 3
• Use appropriate needle size based on patient weight:
  • <90kg: 1-inch 23-gauge needle 3
  • ≥90kg: 1.5-inch 22-gauge needle 3
• After reinitiation, resume monthly maintenance dosing (typically 75mg eq. is recommended, but continue with 150mg if that was your established maintenance dose) 3

Important Administration Considerations

• The deltoid muscle is required for the loading doses to achieve therapeutic concentrations rapidly (approximately 28% higher concentration compared to gluteal injection) 2
• No oral supplementation is required during reinitiation 2, 3
• The day 8 dose may be administered ±2 days without clinically significant impact on plasma concentrations 3

Monitoring After Reinitiation

• Monitor for common side effects including:
  • Injection site reactions (4-10% depending on dose regimen) 2
  • Extrapyramidal symptoms (more common at higher doses) 2
  • Weight changes 2

Prevention of Future Missed Doses

• Set reminders for future doses to improve adherence 4
• Document any missed doses to report to your healthcare provider at your next appointment 5
• Keep extra documentation of injection appointments in multiple locations 5

Clinical Importance of Adherence

• Missing doses of long-acting antipsychotics can lead to symptom recurrence and potential relapse 2
• Proper reinitiation is critical to maintain therapeutic drug levels and clinical efficacy 3
• Following the recommended reinitiation protocol helps ensure optimal clinical outcomes and reduces the risk of hospitalization 6