Invega Sustenna

Indication(s)

Schizophrenia; Schizoaffective Disorder

Dosing available as prefilled syringes

39 mg (injection volume of 0.25 ml) corresponds to a daily oral dose of paliperidone 3 mg

78 mg (injection volume of 0.5 ml) corresponds to a daily oral dose of paliperidone 3 mg

117 mg (injection volume of 0.75 ml) corresponds to a daily oral dose of paliperidone 6 mg

156 mg (injection volume of 1 ml) corresponds to a daily oral dose of paliperidone 9 mg

234 mg (injection volume of 1.5 ml) corresponds to a daily oral dose of paliperidone 12 mg

Recommended starting and maintenance dose

The recommended maintenance dose for treatment of schizophrenia is 117 mg.

Drug Metabolizing Enzyme

CYP3A4

Dosing exclusions

CrCL dosing:

For patients with mild renal impairment (CrCl >/= 50 mL/min to < 80 mL/min: Initiate Sustenna with a dose of 156 mg on treatment day 1, 117 mg one week later. Monthly maintenance dose of 78 mg ; adjust monthly maintenance dose based on tolerability and/or efficacy

Not recommended in patients with moderate or severe renal impairment (CrCl < 50 mL/min)

Loading dose

Loading dose strategy is recommended after tolerability has been established with oral risperidone or paliperidone (for patients naïve to Invega Sustenna):On day 1 administer Invega Sustenna 234 mg in the deltoid muscle.

One week later administer Invega Sustenna 156 mg in the deltoid muscle per medication label.

Seven days is recommended for the second loading dose, but a window of 4-10 days is acceptable.

The first maintenance dose should be administered 5 weeks following the first (of 2) loading doses. Maintenance dose should be selected to correspond with appropriate oral dose equivalent (as detailed above).

The loading dose strategy should NOT be used for patients switching from one LAI to another, i.e., Aristada to Invega Sustenna. For patients at steady-state on a long-acting injectable other than Invega Sustenna, prescribers can initiate Invega Sustenna in place of the next scheduled injection.

Oral overlap

No oral supplementation is necessary.

Establishing tolerability

Prior to initiating Invega Sustenna, establish tolerability with oral paliperidone or risperidone.

Storage

Room temperature

Reconstitution or mixing

N/A

Injection site

Choose between the deltoid or gluteal muscle (for maintenance doses) based on the patient preference and body habitus. Both loading doses should be administered in the deltoid muscle.Rotate injection sites to avoid muscle hypertrophy, abscesses, and tissue damage by repeated, frequent injections at the same site.
For deltoid injections: For patients weighing less than 90 kg, the 1-inch, 23 gauge needle is recommended.
For patients weighing 90 kg or more, the 1 ½-inch, 22 gauge needle is recommended.
For gluteal injections:The recommended needle size for administration of Invega Sustenna into the gluteal muscle is the 1½-inch, 22 gauge needle regardless of patient weight.
Deltoid is specifically recommended for faster distribution during the initiation phase.

Injection interval

Every 4 weeks

Preparation

Shake the syringe vigorously for a minimum of 10 seconds to ensure a homogeneous suspension. Priming the syringe is recommended.

Administration considerations

Administer the injection within 5 minutes of shaking. Inject the entire contents intramuscularly slowly, deep into the selected deltoid or gluteal muscle of the patient.

Timing variations

For initiation dosing: the second initiation dose can be given within a 4 to 10 day window after the first injection.

To avoid a missed maintenance injection, patients may be given the injection up to 7 days before or after the monthly time point.

When a dose is missed

See this tip on how to manage missed doses of Invega Sustenna.
Monthly doses can be flexibly administered one week before or after the scheduled dose to avoid missed doses.

REMS

No

Dose Conversion of Oral Paliperidone to Paliperidone Palmitate LAI

Oral Dose

LAI/IM Dose

Initiate LAI doses

Loading doses – 234 mg day 1, followed by 156 mg day 8, followed by maintenance dose 5 weeks after first injection

Paliperidone 6 mg

Invega Sustenna 117 mg every 4 weeks

Paliperidone 9 mg

Invega Sustenna 156 mg every 4 weeks

Paliperidone 12 mg

Invega Sustenna 234 mg every 4 weeks

Recommended available dose formulations include 39 mg, 78 mg, 117 mg, 156 mg, and 234 mg pre-filled syringes.

Dose reduction may be necessary for CYP450 interactions or side effect intolerance.

References:

1. Stahl, S. M. (2017). The prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). New York: Cambridge University Press.

2. American Psychiatric Association. (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890424841

3. INVEGA SUSTENNA USPI, Section 2.1 Administration Instructions; Section 2.2: Schizophrenia and Schizoaffective Disorder; Section 2.6: Switching from Other Antipsychotics; Section 17: How Supplied/Storage and Handling

4. California Department of State Hospitals Psychotropic Medication Operational Procedures

Invega Trinza

Indication(s)

Schizophrenia

Dosing available as prefilled syringes

273 mg (injection volume of 0.875 ml) 
410 mg (injection volume of 1.315 ml)
546 mg (injection volume of 1.75 ml)
819 mg (injection volume of 2.625 ml)

Recommended starting and maintenance dose

Used only after establishment of 17 weeks of paliperidone palmitate once every 4 weeks injection (last 8 weeks with the same dose); dose based on paliperidone palmitate IM once every 4 weeks dose

Drug Metabolizing Enzyme

CYP3A4

Dosing exclusions

Invega Trinza is not recommended in patients with moderate or severe renal impairment

Loading dose

Dose equivalence to paliperidone palmitate once every 4 weeks:

39 mg Invega paliperidone palmitate once every 4 weeks to N/A for Trinza

78 mg of Invega paliperidone palmitate once every 4 weeks to 273 mg for Trinza

117 mg Invega paliperidone palmitate once every 4 weeks to 410 mg Trinza

156 mg paliperidone palmitate once every 4 weeks to 546 mg Trinza

234 mg paliperidone palmitate once every 4 weeks to 819 Trinza

Oral overlap

None required.

Establishing tolerability

Prior to initiating Invega Trinza, treat the patient with 4 week formulation of paliperidone palmitate for at least 17 weeks to ensure optimal dosing. To establish a consistent maintenance dose, it is recommended that the last two doses of paliperidone palmitate once every 4 weeks be the same dosage strength before starting Invega Trinza.

Storage

Room temperature

Reconstitution or mixing

No reconstitution required.

Injection site

Choose between the deltoid or gluteal muscle based on the patient preference and body habitus. Rotate injection sites to avoid muscle hypertrophy, abscesses, and tissue damage by repeated frequent injections at the same site.

Injection interval

Every 12 weeks

Preparation

With the syringe tip pointing up, shake vigorously with a loose wrist for at least 15 seconds to ensure a homogeneous suspension. If more than 5 minutes pass before injection, shake vigorously, with the syringe tip pointing up, again for at least 15 seconds to re-suspend the medication. Priming the syringe is recommended.

Administration considerations

Inject the entire contents intramuscularly slowly, deep into the selected deltoid or gluteal muscle of the patient.
The thin-walled needles included in the Invega Trinza kit must be used for the injection.

Timing variations

To avoid a missing dose: patients may be given the injection up to 2 weeks before or after the 13 week time point.

When a dose is missed

If a patient has missed a dose and it is 15 weeks to 17 weeks since the last injection: the previously administered Trinza dose should be administered as soon as possible, then continue with the 13 week injections following the dose.

If 17 weeks to 39 weeks since last injection: This requires re-initiation via table 2 in the package insert.

REMS

No

Dose Conversion of Oral Paliperidone to Paliperidone Palmitate 12-week LAI

Oral Dose

LAI/Paliperidone Palmitate Once Monthly Dose **Stabilization with Paliperidone Palmitate Once Monthly required prior to initiation of Invega Trinza

LAI/Invega Trinza Dose

Paliperidone < 3 mg

Paliperidone Palmitate 39 mg once monthly every 4 weeks

Paliperidone 3 mg

Paliperidone Palmitate 78 mg once monthly every 4 weeks

Invega Trinza 273 mg every 12 weeks

Paliperidone 6 mg

Paliperidone Palmitate 117 mg once monthly every 4 weeks

Invega Trinza 410 mg Invega Trinza every 12 weeks

Paliperidone 9 mg

Paliperidone Palmitate 156 mg once monthly every 4 weeks

Invega Trinza 546 mg Invega Trinza every 12 weeks

Paliperidone 12 mg

Paliperidone Palmitate 234 mg once monthly every 4 weeks

Invega Trinza 819 mg Invega Trinza every 12 weeks

Recommended available dose formulations include 273 mg, 410 mg, 546 mg, and 819 mg pre-filled syringes.

Dose reduction may be necessary for CYP450 interactions or side effect intolerance.

References:

1. Stahl, S. M. (2017). The prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). New York: Cambridge University Press.

2. American Psychiatric Association. (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890424841

3. INVEGA SUSTENNA USPI, Section 2.8: Instructions for Use; Section 17: How Supplied/Storage and Handling

4. Erzofri USPI, Section 2.7: Preparation and Administration Instructions; Section 16: How Supplied/Storage and Handling

5. California Department of State Hospitals Psychotropic Medication Operational Procedures. (2025). Chapter 20.

Risperdal Consta/Risperidone for Extended-Release Injectable Suspension

Indication(s)

Schizophrenia

Dosing available

12.5 mg (2 mL)
25 mg (2 mL)
37.5 mg (2 mL)
50 mg (2 mL)

Recommended starting and maintenance dose

The recommended dose is 25 mg IM every 2 weeks.

Risperdal Consta is initiated with the 25 mg dose unless clinical factors suggest to start with 12.5 mg.

Drug Metabolizing Enzyme

CYP2D6, CYP3A4

Dosing exclusions

Patients with renal or hepatic impairment should be treated with titrated doses of oral risperidone prior to initiating treatment with Risperdal Consta.

Loading dose

No established loading-dose strategy.

Oral overlap

Initiating Risperdal Consta requires overlap with oral risperidone (at a therapeutic dose) for 3 weeks.

Risperdal Consta 12.5 mg IM every two weeks corresponds to 1 mg oral risperidone per day. This means that the highest available Risperdal Consta dose of 50 mg IM every two weeks corresponds to 4-5 mg oral per day. For many patients with chronic schizophrenia, this is at the low end of the dose range. Since Risperdal Consta injections should not be combined, clinicians sometimes supplement Risperdal Consta with oral risperidone if a higher dose is desired.

Establishing tolerability

Prior to initiating Risperdal Consta, establish tolerability with oral risperidone in risperidone-naïve patients.

Storage

Requires refrigeration

Reconstitution or mixing

Use only components of the pre-packed dose packages containing the medication and syringe prefilled with diluent. Follow instructions from package insert regarding reconstitution.

Injection site

Deltoid or gluteal injections are bioequivalent; the site can be chosen based on patient preference. Alternate sites and use 1-inch needle for deltoid, 2-inch needle for gluteal injection.

Injection interval

Every 2 weeks

Preparation

Allow product to come to room temperature for at least 30 minutes before reconstituting.  Flip the cap from the vial.  Attach the vial adapter to the vial.  Swab the syringe connection point with an alcohol pad.  Snap the white cap off the prefilled syringe.  Attach the syringe to the vial adapter.  Inject the entire contents of the syringe containing the diluent into the vial. Shake the vial vigorously while holding the plunger rod down with the thumb for a minimum of 10 seconds to ensure a homogeneous suspension.  If 2 minutes pass before injection, re-suspend by shaking vigorously.  Invert the vial completely and slowly withdraw the suspension from the vial into the syringe.  Unscrew the syringe from the vial adapter and inject per package insert instructions.  Priming of the syringe is recommended.

Administration considerations

The injection is water-based which is less painful than decanoates. You don’t need to push hard.

Always give the full vial that you selected (the microspheres are not evenly distributed in the syringe). You should also not combine different doses of Risperdal Consta.

When a dose is missed

Refer to this tip on how to address missed doses.

REMS

No

Additional information

Adjustment in dose should not be made more frequently than every 4 weeks.
This product is now available generically. 

Dose Conversion of Oral Risperidone to Risperidone Microspheres LAI

Oral Daily Dose

LAI/IM Dose

1 mg daily

12.5 mg (injection volume of 2 ml) every 2 weeks

2 mg daily

25 mg (injection volume 2 ml) every 2 weeks

3-5 mg daily

37.5 mg (injection volume 2 ml) every 2 weeks

4-5 mg daily

50 mg (injection volume 2 ml) every 2 weeks

Recommended available dose formulations include 12.5 mg, 25 mg, 37.5 mg, and 50 mg pre-filled vial kits.

Dose reduction may be necessary for CYP450 interactions, in patients with hepatic or renal impairment, or in patients who have a history of poor tolerability to psychotropic medications.

References:

1. Bai, Y.M., Chen, T.T., Chen, J-Y., Chang, W-H., Wu, B., Hung, C.H., & Lin, W.K. (2007). Equivalent switching dose from oral risperidone to risperidone long-acting injection: A 48-week randomized, prospective, single-blind pharmacokinetic study . Journal of Clinical Psychiatry, 68(8), 1218-1225. doi: 10.4088/jcp.v68n0808.

2. Stahl, S. M. (2017). The prescriber’s guide: Stahl’s essential psychopharmacology (6th ed.). New York: Cambridge University Press.

3. American Psychiatric Association. (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890424841

4. RISPERDAL CONSTA USPI Section 2.1: Schizophrenia; Section 2.2: Bipolar Disorder; Section 2.3: General Dosing Information; Section 2.8: Instructions for Use

5. Taylor, D.M., Barnes, T.R.E, & Young, A.H. (2021). The Maudsley prescribing guidelines in psychiatry (14th ed.). Wiley Blackwell.

6. California Department of State Hospitals Psychotropic Medication Operational Procedures

Uzedy 

Indication(s)

Schizophrenia; Bipolar I Maintenance

Dosing available as prefilled syringes

50 mg/0.14 mL
75 mg/0.21 mL
100 mg/0.28 mL
125 mg/0.35 mL
150 mg/0.42 mL
200 mg/0.56 mL
250 mg/0.7 mL 

Recommended starting and maintenance dose

To start: Switch from oral daily risperidone. Initiate as either once monthly injection or a once every 2 month injection, the day after the last dose of oral therapy. See table 1 in package insert to determine oral dose.

Drug Metabolizing Enzyme

CYP2D6, CYP3A4

Dosing exclusions

In patients with renal or hepatic impairment, titrate with oral risperidone (up to at least 2 mg daily) before initiating Uzedy.

Loading dose

No loading dose recommended

Oral overlap

No oral supplementation recommended

Establishing tolerability

Prior to initiating Uzedy, establish tolerability with oral risperidone in risperidone-naïve patients.

Storage

Requires refrigeration. May store for up to 90 days in its unopened original packaging at room temperature.

Reconstitution or mixing

Doesn't require reconstitution.

Injection site

Subcutaneously in the abdomen or back of the upper arm

Injection interval

Every 4 or 8 weeks

Preparation

Allow product to come to room temperature for at least 30 minutes. Uzedy is a solid at refrigerated temperatures and must reach room temperature prior to administration. Whip the syringe forcefully three times to move the bubble to the cap. Standing while you do this may help achieve required force. Holding the syringe up to a light or against a dark backdrop may improve visibility. If the bubble is not at the cap, repeat the whipping until it is. Bend and snap off the cap and attach the needle. Do not prime the syringe.  Inject per the package insert instructions.

Administration considerations

Select the injection site: subcutaneously in the abdomen or back of the upper arm.  See package insert for full details.  Pinch at least 1 inch of the selected area.  Insert the needle into subcutaneous tissue.  Release the pinched skin once the needle is in the subcutaneous tissue.  Inject the medication- using a slow, firm, and steady push until the entire dose is delivered.  Inject the entire dose at one time, without interruption.  Resistance will be experienced during dose delivery.  Do not use excessive force in an attempt to deliver Uzedy faster.  Wait 2-3 seconds after the entire dose is delivered before removing the needle.  Slowly pull the needle out from the injection site at the same angle as insertion.

Timing variations

N/A

When a dose is missed

When a dose of Uzedy is missed, administer the next Uzedy injection as soon as possible. See this tip for more information.

REMS

No

Additional information

Patients who are stable on oral risperidone doses lower than 2 mg/day or higher than 5 mg/day may not be candidates for Uzedy.
The medication provides a quick initial release.

Dose Conversion of Oral Risperidone to Uzedy™

Oral Dose

Uzedy Dosage Once Monthly

Uzedy Dosage Once Every 2 Months

Risperidone 2 mg daily

50 mg

100 mg

Risperidone 3 mg daily

75 mg

150 mg

Risperidone 4 mg daily

100 mg

200 mg

Risperidone 5 mg daily

125 mg

250 mg

Reference: Teva Neuroscience, Inc. (2023). Uzedy prescribing information.