Paliperidone for schizophrenia
The efficacy, safety, pharmacology, pharmacokinetics, drug-drug interactions, and administration of paliperidone for schizophrenia are reviewed.
Paliperidone is a benzisoxazole derivative and the principal active metabolite of risperidone. Representative of most oxidative metabolites, paliperidone is less lipophilic than risperidone. Like other atypical antipsychotics, paliperidone has a greater affinity for serotonin type 2A- receptor blockade relative to dopamine type 2-receptor blockade. Paliperidone's advanced-generation osmotic release delivery system allows for the avoidance of dosage adjustment when initiating therapy and may decrease the frequency of antido-paminergic effects that would occur with an immediate-release formulation. The pharmacologic actions of paliperidone are similar to other high potency atypical antipsychotics. The receptor-binding profile of paliperidone most closely resembles that of risperidone and ziprasidone. Paliperidone differs from risperidone and most other antipsychotics by its relatively low extent of enzymatic metabolism. A limited number of investigations have demonstrated the ability of paliperidone to produce significant improvements in psychopathology, functioning, and relapse in patients with schizophrenia when compared with placebo. Paliperidone appears to have a similar adverse-effect profile compared to risperidone, except for an increased rate of hyperprolactinemia. The recommended dose of paliperidone for the treatment of adults with schizophrenia is 6 mg every morning.
Paliperidone does not offer any clear advantage over other atypical antipsychotics with a similar receptor-binding profile, such as risperidone and ziprasidone. Nevertheless, a few investigations have demonstrated the ability of paliperidone to produce significant improvements in psychopathology, functioning, and relapse when compared with placebo. Based on limited studies, the frequency of adverse effects, except for hyperprolactinemia, appears to favor paliperidone over risperidone.
Available from: Andreas Schreiner
- "Paliperidone ER has a greater affinity for serotonin type 2A (5-HT2A) receptor relative to dopamine type 2 (D2) receptor and a very low affinity for muscarinic receptors [60,61]. A dose of 6–9 mg of paliperidone ER provides a mean D2 receptor occupancy of 70%–80%, reflecting the accepted receptor occupancy range required for optimal antipsychotic activity without increased risk of EPS . "
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ABSTRACT: Many patients with schizophrenia receive long-term treatment with antipsychotic medication. Switching of antipsychotic medication due to lack of efficacy, tolerability issues, and partial/non-adherence is common. Despite this, consensus strategies for switching between antipsychotics are lacking. This manuscript provides practical recommendations for switching antipsychotic medication to ensure optimal management of patients with schizophrenia, with a particular focus on paliperidone extended release (ER). The authors drew on their clinical experience supported by detailed discussion of literature describing antipsychotic switching techniques and strategies and findings from paliperidone ER clinical trials. Antipsychotic switching strategies should be individualized and take into consideration the pharmacokinetic (PK) and pharmacodynamic (PD) properties of the pre- and post-switch medication. The use of temporary concomitant medications may be appropriate in some scenarios. Abrupt withdrawal of pre-switch medication may be appropriate in some instances but carries a greater risk of rebound and withdrawal symptoms than other strategies. Cross-tapering is the method most widely used in clinical practice. Paliperidone ER can be initiated without dose titration. The EU SmPC recommended dose of paliperidone ER is 6 mg/day; but doses should be individualized within the approved range of 3-12 mg/day. Higher doses may be required due to insufficient efficacy of the previous antipsychotic or in patients with acute symptoms. Recently diagnosed patients, those with renal impairment, or patients who have previously experienced tolerability issues with other antipsychotics may require lower doses. When switching from risperidone, higher doses of paliperidone ER may be required compared with risperidone. When switching from antipsychotics that have sedative and/or significant anticholinergic activity, the pre-switch antipsychotic should be tapered off gradually. Antipsychotics with less sedating and little anticholinergic activity can be tapered off over a shorter period. Temporary concomitant sedative medication may be beneficial when switching from antipsychotics with relatively higher sedative propensities. Switching from another antipsychotic to paliperidone ER requires individualized switching strategies and dosing, dependent on the characteristics of the patient and the PK and PD properties of the pre-switch medication. Cross-tapering strategies should be considered as a means of reducing the risk of rebound and withdrawal symptoms.
Available from: PubMed Central
- "Several clinical trials evaluated effectiveness of paliperidone ER in treating schizophrenia [15, 22, 27, 28]. In particular, recent studies ascertained significant improvements in positive symptoms, negative symptoms, depression and anxiety, uncontrolled hostility/excitement, and disorganized thoughts [27, 29]. "
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ABSTRACT: Antipsychotics are recommended for the treatment of impulsive dyscontrol and cognitive perceptual symptoms of borderline personality disorder (BPD). Three reports supported the efficacy of oral risperidone on BPD psychopathology. Paliperidone ER is the metabolite of risperidone with a similar mechanism of action, and its osmotic release reduces plasmatic fluctuations and antidopaminergic effects. The aim of this study is to evaluate efficacy and safety of paliperidone ER in BPD patients. 18 outpatients with a DSM-IV-TR diagnosis of BPD were treated for 12 weeks with paliperidone ER (3-6 mg/day). They were assessed at baseline, week 4, and week 12, using the CGI-Severity item, the BPRS, the HDRS, the HARS, the SOFAS, the BPD Severity Index (BPDSI), and the Barratt Impulsiveness Scale (BIS-11). Adverse events were evaluated with the DOTES. Paliperidone ER was shown to be effective and well tolerated in reducing severity of global symptomatology and specific BPD symptoms, such as impulsive dyscontrol, anger, and cognitive-perceptual disturbances. Results need to be replicated in controlled trials.
Available from: PubMed Central
- "There were nine nonsystematic reviews and one systematic review.2 Declarations of interest were missing in two cases.3,8 For the other eight publications, the authors had direct affiliations with Janssen-Cilag or Johnson & Johnson (in particular, authors received honoraria from Janssen-Cilag and conducted clinical research with the support of Janssen-Cilag,1 authors were employed by Johnson & Johnson,4 one author was on the speakers’ bureau for Janssen,5 the authors had received honoraria for lectures supported by Janssen-Cilag and received fees for advisory board and congress presentations,6 one author had been a consultant for Janssen-Cilag,2 one author has received research grants and speakers’ honoraria from Janssen-Cilag,7 one author was employed within Janssen-Cilag, was a member of the speakers’ bureau for Janssen-Cilag, and an advisor/consultant for Janssen-Cilag, with editorial support and funding from Ortho-McNeil Janssen Scientific Affairs,9 and during the peer review process the manufacturer of PER was offered an opportunity to comment on the article10). "
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ABSTRACT: Paliperidone (9-hydroxy-risperidone), the active metabolite of risperidone, was approved for treating schizophrenia worldwide in 2006 as paliperidone extended-release (PER), and became the first second-generation antipsychotic specifically licensed for treating schizoaffective disorder in 2009. However, at the same time, its comparatively high cost gave rise to concerns about the cost-effectiveness of PER as compared with its precursor, risperidone. This paper reviews the existing knowledge of the pharmacology, kinetics, efficacy, tolerability, and fields of application of PER, and compares PER with risperidone in order to determine whether it has a place in antipsychotic therapy. An independent assessment of all relevant publications on PER published until July 2010 was undertaken. PER has a unique pharmacological profile, including single dosing, predominantly renal excretion, low drug-drug interaction risk, and differs from risperidone in terms of mode of action and pharmacokinetics. High-level evidence suggests that PER is efficacious and safe in schizophrenia, schizoaffective disorder, and acute manic episodes. There is a striking lack of published head-to-head comparisons between PER and risperidone, irrespective of indication. Low-level evidence shows a lower risk for hyperprolactinemia and higher patient satisfaction with PER than with risperidone. PER adds to the still limited arsenal of second-generation antipsychotics. In the absence of direct comparisons with risperidone, it remains difficult to come to a final verdict on the potential additional therapeutic benefits of PER which would justify its substantially higher costs as compared with risperidone. However, in terms of pharmacology, the available evidence cautiously suggests a place for PER in modern antipsychotic therapy.
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