What should clinicians know about Invega Sustenna (paliperidone palmitate LAI)?

Invega Sustenna (“Sustenna” or paliperidone palmitate) is a long-acting injectable (LAI) formulation of paliperidone. It was the first available second-generation antipsychotic LAI to provides coverage for 4 weeks. It is FDA-indicated to treat adults with diagnoses of schizophrenia and schizoaffective disorder.

Establishing Tolerability

Dosing

  • Once every 4 week intramuscular injection only, which must be administered by a healthcare provider.
  • Available as prefilled syringes of the following doses:
    • 39 mg corresponds to a daily oral dose of < 3 mg paliperidone
    • 78 mg corresponds to a daily oral dose of paliperidone 3 mg
    • 117 mg corresponds to a daily oral dose of paliperidone 6 mg
    • 156 mg corresponds to a daily oral dose of paliperidone 9 mg
    • 234 mg corresponds to a daily oral dose of paliperidone 12 mg

      Dose Conversion of Oral Paliperidone to Paliperidone Palmitate LAI

      PO 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

      < 3 mg paliperidone

      39 mg Invega Sustenna every 4 weeks

      3 mg paliperidone

      78 mg Invega Sustenna every 4 weeks

      6 mg paliperidone

      117 mg Invega Sustenna every 4 weeks

      9 mg paliperidone

      156 mg Invega Sustenna every 4 weeks

      12 mg paliperidone

      234 mg Invega Sustenna every 4 weeks

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

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

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

  • The following 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.
    • One week later administer Invega Sustenna 156 mg in the deltoid per medication label, while using clinical judgment. (Published data suggests Invega Sustenna 234 mg for both initiation doses and maintenance is safe.)
    • 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 deltoid is specifically recommended for faster distribution during the initiation phase.
    • No oral supplementation is necessary.
    • The loading dose strategy should NOT be used for patients switching from one LAI to another, i.e., Aristada to Invega Sustenna. Detailed protocols for switching between LAIs have not been established, but it is recommended that there is overlap of 1-3 weeks when switching to oral paliperidone. Therefore, prescribers should stop the previous LAI and initiate the new LAI at targeted maintenance dose when possible.
  • See this tip on how to manage missed doses of Invega Sustenna.

Practical issues (including administration)

  • Store Invega Sustenna at room temperature.
  • Shake the pre-filled syringe vigorously for 10 seconds. Administer the injection within 5 minutes of shaking.
  • Monthly doses can be flexibly administered one week before or after the scheduled dose to avoid missed doses.
  • 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.
    • Use 1-inch needle for deltoid, 2-inch needle for gluteal injection.

FDA medication label

  • Information on this topic is found in the FDA medication label. Here is the most recent label, at time of writing.
  • Medication labels can be found by searching Drugs@FDA at the FDA website. Labels are also available using the Drugs@FDA app for Apple or Android devices. Labels change over time, and the current label should always be consulted.

Administration/dosing guide

  • More information about administration and dosing can be found here and in this detailed video
If you would like more information on this topic, or would like to provide any feedback, please send us a message using our consultation system. Be sure to let us know about which tip you are writing. We would love to hear from you, and the consultation system is free to use and confidential. Thank you!
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