What is the recommended dosing for Invega (paliperidone) in adults with schizophrenia?

Invega (Paliperidone) Dosing for Schizophrenia in Adults

For adults with schizophrenia, start Invega (paliperidone extended-release) at 6 mg once daily without initial dose titration, with a therapeutic range of 3-12 mg/day based on individual response and tolerability. 1

Standard Dosing Regimen

Initial Dose

• Begin at 6 mg once daily - this is the recommended starting dose and no titration is required 1
• The 6 mg dose is immediately therapeutic and does not require gradual escalation 1

Dose Adjustments

• If dose increases are needed: Make increments of 3 mg/day only after clinical reassessment 1
• Timing of dose changes: Wait at least 5 days between dose increases 1
• Maximum dose: 12 mg/day 1
• Lower doses: Some patients may respond adequately to 3 mg/day 1

Important Dosing Considerations

• While higher doses (up to 12 mg/day) show a trend toward greater efficacy, this must be balanced against dose-related adverse reactions 1
• The FDA label notes that systematic evidence for additional benefit above 6 mg is limited, though some patients do respond better to higher doses 1

Administration Instructions

• Take with or without food - meals do not affect administration 1
• Swallow tablets whole - do not chew, divide, or crush the extended-release formulation 1
• Use liquids to aid swallowing 1

Special Population Adjustments

Renal Impairment

• Mild impairment (CrCl 50-79 mL/min): Start at 3 mg once daily, maximum 6 mg/day 1
• Moderate to severe impairment (CrCl 10-49 mL/min): Start at 1.5 mg once daily, maximum 3 mg/day 1
• Severe impairment (CrCl <10 mL/min): Not recommended - paliperidone has not been studied in this population 1

Hepatic Impairment

• Mild to moderate (Child-Pugh A and B): No dose adjustment needed 1
• Severe hepatic impairment: Not studied, use with caution 1

Elderly Patients

• Dose according to renal function status, as elderly patients often have diminished renal function 1
• For those with normal renal function, use standard adult dosing 1
• For moderate to severe renal impairment, maximum dose is 3 mg once daily 1

Duration of Treatment Trial

• Assess efficacy after 4 weeks at therapeutic doses with documented good adherence before considering a switch 2, 3
• This aligns with current schizophrenia treatment guidelines that recommend 4-6 week trials at therapeutic doses 3
• If switching from a D2 partial agonist as first-line treatment, paliperidone is an appropriate second-line option 2

Critical Warnings

Contraindications

• Known hypersensitivity to paliperidone or risperidone or any excipients in the formulation 1

Risperidone Coadministration

• Avoid concurrent use with risperidone - paliperidone is the major active metabolite of risperidone, creating additive exposure risk 1
• If combination is unavoidable, consider the cumulative paliperidone exposure 1

Black Box Warning

• Not approved for dementia-related psychosis - elderly patients with dementia-related psychosis treated with antipsychotics have increased mortality risk 1

Long-Term Maintenance

• Prescribe at the lowest effective dose for maintaining clinical stability 1
• Periodically reevaluate long-term usefulness in individual patients 1
• Paliperidone has demonstrated efficacy in delaying time to relapse when patients are stabilized for 6 weeks 1