Difficulties transitioning to Invega Sustenna

[deleted456421]

I've had two patients that decompensated during transitions to Sustenna.

The first was very, very carefully titrated to 9 mg of oral paliperidone with almost complete remittance of psychosis before starting Sustenna. They were admitted for NMS after stopping Trinza and being overloaded with various antipsychotics at another hospital, so I wanted to make sure it wouldn't recur before restarting a long-acting injectable. I followed the manufacturer recommendations exactly (234 mg on day 1 and 156 mg on day 8) and discontinued oral Invega. They decompensated 2 days after the 2nd IM and required an additional two months of oral supplementation before discharge. This was in a thin individual, for whatever that's worth.

The second was doing great on Risperidone Consta but was threatening to stop the injection because of its frequency. I smartly told the patient and their mother that I had an easy trick: we'd switch to Sustenna, then Trinza, then Halyera. I showed them the manufacture's colorful website (here for those interested) and promised a simple transition. Again, I followed the recommendations exactly (they were on Consta 50 mg/biweekly so I transitioned to Sustenna 156 mg/monthly). Again, they experienced dramatically worsened auditory hallucinations and disorganization.

Has anyone else had similar experiences or know something about the pharmacokinetics of paliperidone that I'm missing?

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[Candidate2017]

The manufacturer says no Invega PO overlap is needed, but most psychiatrists continue Invega PO for 7-14 days. If no PO overlap is given, the decompensation usually isn't very severe, and temporary increase in anxiolytics and sleep meds helps, and patients stabilize in 7-14 days. Severe patients may need Sustenna 234 as their maintenance dose. Also, Sustenna 156 is a lower dose than Consta 50.

EDIT: Thanks Kirby, sorry, Sustenna 156 is at least equal to Consta 50. Some studies say it's greater. Either way, Invega PO overlap (rather than Risperdal PO) should help the transition to Sustenna; Invega PO has a much shorter half life and any side effects will wash out quicker than Risperdal PO if you need to stop the oral overlap.

 

[deleted456421]

The manufacturer says no Invega PO overlap is needed, but most psychiatrists continue Invega PO for 7-14 days. If no PO overlap is given, the decompensation usually isn't very severe, and temporary increase in anxiolytics and sleep meds helps, and patients stabilize in 7-14 days. Severe patients may need Sustenna 234 as their maintenance dose. Also, Sustenna 156 is a lower dose than Consta 50.

Appreciate it. I previously worked with a fairly experienced psychiatrist and they agreed an overlap wasn’t necessary. Now I know.

 

[deleted456421]

Sustenna 156 is a lower dose than Consta 50.

Where did you find that? I see several resources saying 50 of Consta = 156 of Sustenna.

 

[deleted1100659]

Interesting; i have not had that issue personally, and sustenna is of the top 3 LAIs I use. I do not use oral overlap with it, because I mainly use it in people who are noncompliant with the oral so its likely they wouldnt take the oral anyways.

We only have 1 person on trinza in my facility, because I think 3month LAis are more ideal for younger people, with less severe psychosis.

How long were they stable on the 9mg dose before going to the LAI? Is it possible residual effeects of other antipsychotics were keeping them stable?

 

[deleted456421]

Interesting; i have not had that issue personally, and sustenna is of the top 3 LAIs I use. I do not use oral overlap with it, because I mainly use it in people who are noncompliant with the oral so its likely they wouldnt take the oral anyways.

We only have 1 person on trinza in my facility, because I think 3month LAis are more ideal for younger people, with less severe psychosis.

How long were they stable on the 9mg dose before going to the LAI? Is it possible residual effeects of other antipsychotics were keeping them stable?

The person with NMS received an acute course of ECT with tapering over two months. I slowly titrated PO paliperidone over a month or so. It's entirely possible ECT was still contributing (in fact, I initially thought it was recurrent NMS but they never demonstrated the motor signs or autonomic instability).

The other person had been stable on Consta for many months.

 

[deleted456421]

We only have 1 person on trinza in my facility, because I think 3month LAis are more ideal for younger people, with less severe psychosis.

I presume you avoid it in older individuals due to concerns about parkinsonism? Any particular reason you don't like it in those with severe psychosis?

 

[deleted1100659]

I presume you avoid it in older individuals due to concerns about parkinsonism? Any particular reason you don't like it in those with severe psychosis?

It doesnt seem to last the full 3 months- unclear if thats because the patients themselves become concerned that its been a while since their last shot and the anxiety provokes their symptoms, or because the effect isnt as durable. Plus I like knowning that my severe patients are coming into the lab once a month at least doing a couple mins of check up time with other staff, getting their LAI. And I can get sustenna covered easier than trinza

Someone younger and less severe, I worry less about them relapsing compared to the aforementioned patients.

Geriatric I try to mainly use seroquel and zyprexa, or abilify if I can get away with it I dont like using LAIs on them, but sometimes you dont have a choice.

 

[deleted456421]

It doesnt seem to last the full 3 months- unclear if thats because the patients themselves become concerned that its been a while since their last shot and the anxiety provokes their symptoms, or because the effect isnt as durable. Plus I like knowning that my severe patients are coming into the lab once a month at least doing a couple mins of check up time with other staff, getting their LAI. And I can get sustenna covered easier than trinza

Someone younger and less severe, I worry less about them relapsing compared to the aforementioned patients.

Geriatric I try to mainly use seroquel and zyprexa, or abilify if I can get away with it I dont like using LAIs on them, but sometimes you dont have a choice.

Sound reasoning. The state I work in is pretty good about covering visiting nurses; the only people coming for their injections are those with crappy insurance (often really low end private insurance).

Now that I think about it, everyone I have on Trinza is fairly young.