Starting Dose of Invega (Paliperidone) for Adults with Schizophrenia
The recommended starting dose of Invega (paliperidone extended-release) for adults with schizophrenia is 6 mg administered once daily, with no initial dose titration required. 1
Dosing Algorithm
Standard Adult Dosing
- Initial dose: 6 mg once daily - this is both the starting and therapeutic dose for most patients 1
- No titration needed - patients can begin at the therapeutic dose immediately 1
- Dose range: 3-12 mg/day - some patients may require adjustment based on clinical response 1
When to Adjust from 6 mg Starting Dose
Lower doses (3 mg/day):
- Patients with mild renal impairment (CrCl 50-80 mL/min) should start at 3 mg once daily, with maximum dose of 6 mg/day 1
- Patients with moderate to severe renal impairment (CrCl 10-50 mL/min) should start at 1.5 mg once daily, with maximum dose of 3 mg/day 1
- Elderly patients may require dose reduction based on renal function status 1
Higher doses (up to 12 mg/day):
- If positive symptoms persist after 4 weeks at 6 mg/day with good adherence, consider dose increases 1
- Increase in 3 mg increments at intervals of more than 5 days 1
- Maximum recommended dose is 12 mg/day 1
- Important caveat: Higher doses show a general trend for greater effects but must be weighed against dose-related adverse reactions 1
Administration Details
- Can be taken with or without food 1
- Must be swallowed whole - tablets cannot be chewed, divided, or crushed 1
- Once-daily dosing provides stable plasma concentrations over 24 hours 2, 3
Critical Considerations
Renal Function Assessment
- Always assess renal function before initiating therapy - this is the most important factor determining starting dose 1
- Paliperidone undergoes limited hepatic metabolism, making renal function the primary determinant of dosing 3
- No dose adjustment needed for hepatic impairment (Child-Pugh A and B) 1
Concomitant Risperidone Use
- Avoid combining with risperidone - paliperidone is the major active metabolite of risperidone, creating additive exposure risk 1
Clinical Response Timeline
- Assess efficacy at 4 weeks - if significant positive symptoms persist with good adherence at therapeutic dose, consider switching to alternative antipsychotic rather than automatic dose escalation 4, 1
- Clinical response can be seen as early as 4 days in some patients 2
Common Pitfalls to Avoid
Do not titrate unnecessarily - unlike many antipsychotics, paliperidone ER does not require gradual titration and can start at the therapeutic dose of 6 mg 1
Do not crush or split tablets - the extended-release formulation requires intact tablets for proper drug delivery 1
Do not overlook renal function - failure to adjust for renal impairment can lead to excessive drug exposure and increased adverse effects 1
Do not automatically escalate to higher doses - doses above 6 mg show only a general trend for greater effects while clearly increasing adverse reactions 1