Increasing Invega Sustenna from 156 mg
After the initial loading doses are complete, increase the monthly maintenance dose from 156 mg to the maximum dose of 234 mg, administered as a single intramuscular injection in either the deltoid or gluteal muscle. 1, 2
Dose Escalation Strategy
The available evidence supports the following approach for dose increases:
Maintenance dose range: Following the initial loading regimen, monthly maintenance doses range from 39 mg to 234 mg equivalents, with higher doses (156 mg and 234 mg) demonstrating consistently better therapeutic response 3
Maximum recommended dose: The 234 mg dose represents the upper limit for monthly maintenance therapy and showed the lowest number needed to treat (NNT) for achieving ≥30% reduction in symptom scores 3
Timing of dose adjustment: Increase the dose at the next scheduled monthly injection (4 weeks after the previous dose) 1, 2
Injection site considerations: Both deltoid and gluteal administration are acceptable for maintenance dosing, though deltoid injection produces approximately 28% higher maximum plasma concentrations 3
Clinical Rationale for Dose Increase
Dose-response relationship: Studies consistently demonstrate superior efficacy at the 156 mg and 234 mg dose strengths compared to lower doses, with evidence of a therapeutic dose-response curve 3
Symptom control: If the patient continues to experience inadequate symptom control on 156 mg, escalation to 234 mg is the appropriate next step before considering alternative strategies 2
Critical Safety Considerations
Extrapyramidal symptoms (EPS): Higher doses are associated with increased rates of EPS, though overall rates remain relatively low 3
Weight gain: Monitor for increased weight gain at higher doses, as this adverse effect may be more common with dose escalation 3
Injection site reactions: Expect injection site reactions in 4-10% of patients, compared to 2% with placebo 3
Cardiovascular monitoring: Be vigilant for tachycardia, hypotension, and QT prolongation, particularly with higher plasma concentrations 4
Common Pitfalls to Avoid
Avoid oral supplementation: Unlike risperidone long-acting injection, paliperidone palmitate does not require oral antipsychotic supplementation when adjusting maintenance doses 3, 1
Do not exceed monthly dosing interval: The medication is designed for once-monthly administration; more frequent dosing is not recommended 1
Recognize biphasic pharmacokinetics: Paliperidone palmitate has a complex biphasic release profile—alterations in particle size or formulation could significantly impact clinical effects, so only use the branded product 4
Monitor for delayed adverse effects: Therapeutic drug concentrations can persist for up to 126 days, meaning adverse effects from dose increases may be prolonged 3