4.1. Therapeutic indications

Paliperidone STADA is indicated for maintenance treatment of schizophrenia in adult patients stabilised with paliperidone or risperidone.

In selected adult patients with schizophrenia and previous responsiveness to oral paliperidone or risperidone, Paliperidone STADA may be used without prior stabilisation with oral treatment if psychotic symptoms are mild to moderate and a long-acting injectable treatment is needed.

4.2. Posology and method of administration

Posology

Recommended initiation of Paliperidone STADA is with a dose of 150 mg on treatment day 1 and 100 mg one week later (day 8), both administered in the deltoid muscle in order to attain therapeutic concentrations rapidly (see section 5.2). The third dose should be administered one month after the second initiation dose. The recommended monthly maintenance dose is 75 mg; some patients may benefit from lower or higher doses within the recommended range of 25 to 150 mg based on individual patient tolerability and/or efficacy. Patients who are overweight or obese may require doses in the upper range (see section 5.2). Following the second initiation dose, monthly maintenance doses can be administered in either the deltoid or gluteal muscle.

Adjustment of the maintenance dose may be made monthly. When making dose adjustments, the prolonged release characteristics of Paliperidone STADA should be considered (see section 5.2), as the full effect of maintenance doses may not be evident for several months.

Switching from oral prolonged release paliperidone or oral risperidone to Paliperidone STADA

Paliperidone STADA should be initiated as described at the beginning of section 4.2 above. During monthly maintenance treatment with Paliperidone STADA, patients previously stabilised on different doses of paliperidone prolonged release tablets can attain similar paliperidone steady-state exposure by injection. The Paliperidone STADA maintenance doses needed to attain similar steady-state exposure are shown as follows:

Doses of paliperidone prolonged release tablets and Paliperidone STADA needed to attain similar steady-state paliperidone exposure during maintenance treatment

Previous paliperidone prolonged release tablet dose

Paliperidone STADA injection

3 mg daily

25-50 mg monthly

6 mg daily

75 mg monthly

9 mg daily

100 mg monthly

12 mg daily

150 mg monthly

Previous oral paliperidone or oral risperidone can be discontinued at the time of initiation of treatment with Paliperidone STADA. Some patients may benefit from gradual withdrawal. Some patients switching from higher paliperidone oral doses (e.g., 9-12 mg daily) to gluteal injections with Paliperidone STADA may have lower plasma exposure during the first 6 months after the switch. Therefore, alternatively, it could be considered to give deltoid injections for the first 6 months.

Switching from risperidone long acting injection to Paliperidone STADA

When switching patients from risperidone long acting injection, initiate Paliperidone STADA therapy in place of the next scheduled injection. Paliperidone STADA should then be continued at monthly intervals. The one-week initiation dosing regimen including the intramuscular injections (day 1 and 8, respectively) as described in section 4.2 above is not required. Patients previously stabilised on different doses of risperidone long acting injection can attain similar paliperidone steady-state exposure during maintenance treatment with Paliperidone STADA monthly doses according to the following:

Doses of risperidone long acting injection and Paliperidone STADA needed to attain similar paliperidone exposure at steady-state

Previous risperidone long acting injection dose

Paliperidone STADA injection

25 mg every 2 weeks

50 mg monthly

37.5 mg every 2 weeks

75 mg monthly

50 mg every 2 weeks

100 mg monthly

Discontinuation of antipsychotic medicinal products should be made in accordance with appropriate prescribing information. If Paliperidone STADA is discontinued, its prolonged release characteristics must be considered. The need for continuing existing extrapyramidal symptoms (EPS) medicine should be re-evaluated periodically.

Missed doses

Avoiding missed doses

It is recommended that the second initiation dose of Paliperidone STADA be given one week after the first dose. To avoid a missed dose, patients may be given the second dose 4 days before or after the one-week (day 8) time point. Similarly, the third and subsequent injections after the initiation regimen are recommended to be given monthly. To avoid a missed monthly dose, patients may be given the injection up to 7 days before or after the monthly time point.

If the target date for the second Paliperidone STADA injection (day 8 ± 4 days) is missed, the recommended re-initiation depends on the length of time which has elapsed since the patient's first injection.

Missed second initiation dose (< 4 weeks from first injection)

If less than 4 weeks have elapsed since the first injection, then the patient should be administered the second injection of 100 mg in the deltoid muscle as soon as possible. A third Paliperidone STADA injection of 75 mg in either the deltoid or gluteal muscles should be administered 5 weeks after the first injection (regardless of the timing of the second injection). The normal monthly cycle of injections in either the deltoid or gluteal muscle of 25 mg to 150 mg based on individual patient tolerability and/or efficacy should be followed thereafter.

Missed second initiation dose (4-7 weeks from first injection)

If 4 to 7 weeks have elapsed since the first injection of Paliperidone STADA, resume dosing with two injections of 100 mg in the following manner:

1. a deltoid injection as soon as possible

2. another deltoid injection one week later

3. resumption of the normal monthly cycle of injections in either the deltoid or gluteal muscle of 25 mg to 150 mg based on individual patient tolerability and/or efficacy

Missed second initiation dose (> 7 weeks from first injection)

If more than 7 weeks have elapsed since the first injection of Paliperidone STADA, initiate dosing as described for the initial recommended initiation of Paliperidone STADA above.

Missed monthly maintenance dose (1 month to 6 weeks)

After initiation, the recommended injection cycle of Paliperidone STADA is monthly. If less than 6 weeks have elapsed since the last injection, then the previously stabilised dose should be administered as soon as possible, followed by injections at monthly intervals.

Missed monthly maintenance dose (> 6 weeks to 6 months)

If more than 6 weeks have elapsed since the last injection of Paliperidone STADA, the recommendation is as follows:

For patients stabilised with doses of 25 to 100 mg

1. a deltoid injection as soon as possible at the same dose the patient was previously stabilised on

2. another deltoid injection (same dose) one week later (day 8)

3. resumption of the normal monthly cycle of injections in either the deltoid or gluteal muscle of 25 mg to 150 mg based on individual patient tolerability and/or efficacy

For patients stabilised with 150 mg

1. a deltoid injection as soon as possible at the 100 mg dose

2. another deltoid injection one week later (day 8) at the 100 mg dose

3. resumption of the normal monthly cycle of injections in either the deltoid or gluteal muscle of 25 mg to 150 mg based on individual patient tolerability and/or efficacy

Missed monthly maintenance dose (> 6 months)

If more than 6 months have elapsed since the last injection of Paliperidone STADA, initiate dosing as described for the initial recommended initiation of Paliperidone STADA above.

Special populations

Elderly

Efficacy and safety in elderly > 65 years have not been established.

In general, recommended dosing of Paliperidone STADA for elderly patients with normal renal function is the same as for younger adult patients with normal renal function. However, because elderly patients may have diminished renal function, dose adjustment may be necessary (see Renal impairment below for dosing recommendations in patients with renal impairment).

Renal impairment

Paliperidone has not been systematically studied in patients with renal impairment (see section 5.2). For patients with mild renal impairment (creatinine clearance ≥ 50 to < 80 ml/min), recommended initiation of Paliperidone STADA is with a dose of 100 mg on treatment day 1 and 75 mg one week later, both administered in the deltoid muscle. The recommended monthly maintenance dose is 50 mg with a range of 25 to 100 mg based on patient tolerability and/or efficacy.

Paliperidone STADA is not recommended in patients with moderate or severe renal impairment (creatinine clearance < 50 ml/min) (see section 4.4).

Hepatic impairment

Based on experience with oral paliperidone, no dose adjustment is required in patients with mild or moderate hepatic impairment. As paliperidone has not been studied in patients with severe hepatic impairment, caution is recommended in such patients (see section 5.2).

Paediatric population

The safety and efficacy of paliperidone in children and adolescents < 18 years of age have not been established. No data are available.

Method of administration

Paliperidone STADA is intended for intramuscular use only. It must not be administered by any other route. It should be injected slowly, deep into the deltoid or gluteal muscle. Each injection should be administered by a health care professional. Administration should be in a single injection. The dose should not be given in divided injections.

The day 1 and day 8 initiation doses must each be administered in the deltoid muscle in order to attain therapeutic concentrations rapidly (see section 5.2). Following the second initiation dose, monthly maintenance doses can be administered in either the deltoid or gluteal muscle. A switch from gluteal to deltoid (and vice versa) should be considered in the event of injection site pain if the injection site discomfort is not well tolerated (see section 4.8). It is also recommended to alternate between left and right sides (see below).

For instructions for use and handling of Paliperidone STADA, see package leaflet (information intended for medical or healthcare professionals).

Deltoid muscle administration

The recommended needle size for initial and maintenance administration of Paliperidone STADA into the deltoid muscle is determined by the patient's weight. For those ≥ 90 kg, the 1½ inch, 22 gauge needle (38.1 mm x 0.72 mm) is recommended. For those < 90 kg, the 1-inch, 23 gauge needle (25.4 mm x 0.64 mm) is recommended. Deltoid injections should be alternated between the two deltoid muscles.

Gluteal muscle administration

The recommended needle size for maintenance administration of Paliperidone STADA into the gluteal muscle is the 1½-inch, 22 gauge needle (38.1 mm x 0.72 mm). Administration should be made into the upper-outer quadrant of the gluteal area. Gluteal injections should be alternated between the two gluteal muscles.

4.3. Contraindications

Hypersensitivity to the active substance, to risperidone or to any of the excipients listed in section 6.1.

4.4. Special warnings and precautions for use

Use in patients who are in an acutely agitated or severely psychotic state

Paliperidone should not be used to manage acutely agitated or severely psychotic states when immediate symptom control is warranted.

QT interval

Caution should be exercised when paliperidone is prescribed in patients with known cardiovascular disease or family history of QT prolongation, and in concomitant use with other medicinal products thought to prolong the QT interval.

Neuroleptic malignant syndrome

Neuroleptic Malignant Syndrome (NMS), characterised by hyperthermia, muscle rigidity, autonomic instability, altered consciousness, and elevated serum creatine phosphokinase levels has been reported to occur with paliperidone. Additional clinical signs may include myoglobinuria (rhabdomyolysis) and acute renal failure. If a patient develops signs or symptoms indicative of NMS, paliperidone should be discontinued.

Tardive dyskinesia/extrapyramidal symptoms

Medicinal products with dopamine receptor antagonistic properties have been associated with the induction of tardive dyskinesia characterised by rhythmical, involuntary movements, predominantly of the tongue and/or face. If signs and symptoms of tardive dyskinesia appear, the discontinuation of all antipsychotics, including paliperidone, should be considered.

Caution is warranted in patients receiving both, psychostimulants (e.g., methylphenidate) and paliperidone concomitantly, as extrapyramidal symptoms could emerge when adjusting one or both medications. Gradual withdrawal of stimulant treatment is recommended (see section 4.5).

Leucopenia, neutropenia, and agranulocytosis

Events of leucopenia, neutropenia, and agranulocytosis have been reported with paliperidone.

Agranulocytosis has been reported very rarely (< 1/10,000 patients) during post-marketing surveillance. Patients with a history of a clinically significant low white blood cell count (WBC) or a drug-induced leucopenia/neutropenia should be monitored during the first few months of therapy and discontinuation of paliperidone should be considered at the first sign of a clinically significant decline in WBC in the absence of other causative factors. Patients with clinically significant neutropenia should be carefully monitored for fever or other symptoms or signs of infection and treated promptly if such symptoms or signs occur. Patients with severe neutropenia (absolute neutrophil count <1x109/l) should discontinue paliperidone and have their WBC followed until recovery.

Hypersensitivity reactions

Anaphylactic reactions in patients who have previously tolerated oral risperidone or oral paliperidone have been rarely reported during post-marketing experience (see sections 4.1 and 4.8).

If hypersensitivity reactions occur, discontinue use of Paliperidone STADA; initiate general supportive measures as clinically appropriate and monitor the patient until signs and symptoms resolve (see sections 4.3 and 4.8).

Hyperglycaemia and diabetes mellitus

Hyperglycaemia, diabetes mellitus, and exacerbation of pre-existing diabetes including diabetic coma and ketoacidosis, have been reported during treatment with paliperidone. Appropriate clinical monitoring is advisable in accordance with utilised antipsychotic guidelines. Patients treated with paliperidone should be monitored for symptoms of hyperglycaemia (such as polydipsia, polyuria, polyphagia and weakness) and patients with diabetes mellitus should be monitored regularly for worsening of glucose control.

Weight gain

Significant weight gain has been reported with paliperidone use. Weight should be monitored regularly.

Use in patients with prolactin-dependent tumours

Tissue culture studies suggest that cell growth in human breast tumours may be stimulated by prolactin. Although no clear association with the administration of antipsychotics has so far been demonstrated in clinical and epidemiological studies, caution is recommended in patients with relevant medical history. Paliperidone should be used with caution in patients with a pre-existing tumour that may be prolactin-dependent.

Orthostatic hypotension

Paliperidone may induce orthostatic hypotension in some patients based on its alpha-blocking activity. Based on pooled data from the three placebo-controlled, 6-week, fixed-dose trials with oral paliperidone prolonged release tablets (3, 6, 9, and 12 mg), orthostatic hypotension was reported by 2.5 % of subjects treated with oral paliperidone compared with 0.8 % of subjects treated with placebo. Paliperidone should be used with caution in patients with known cardiovascular disease (e.g., heart failure, myocardial infarction or ischaemia, conduction abnormalities), cerebrovascular disease, or conditions that predispose the patient to hypotension (e.g. dehydration and hypovolemia).

Seizures

Paliperidone should be used cautiously in patients with a history of seizures or other conditions that potentially lower the seizure threshold.

Renal impairment

The plasma concentrations of paliperidone are increased in patients with renal impairment and therefore, dose adjustment is recommended in patients with mild renal impairment. Paliperidone is not recommended in patients with moderate or severe renal impairment (creatinine clearance < 50 ml/min) (see sections 4.2 and 5.2).

Hepatic impairment

No data are available in patients with severe hepatic impairment (Child-Pugh class C). Caution is recommended if paliperidone is used in such patients.

Elderly patients with dementia

Paliperidone has not been studied in elderly patients with dementia. Paliperidone should be used with caution in elderly patients with dementia with risk factors for stroke.

The experience from risperidone cited below is considered valid also for paliperidone.

Overall mortality

In a meta-analysis of 17 controlled clinical trials, elderly patients with dementia treated with other atypical antipsychotics, including risperidone, aripiprazole, olanzapine, and quetiapine had an increased risk of mortality compared to placebo. Among those treated with risperidone, the mortality was 4 % compared with 3.1 % for placebo.

Cerebrovascular adverse reactions

An approximately 3-fold increased risk of cerebrovascular adverse reactions has been seen in randomised placebo-controlled clinical trials in the dementia population with some atypical antipsychotics, including risperidone, aripiprazole, and olanzapine. The mechanism for this increased risk is not known.

Parkinson's disease and dementia with Lewy bodies

Physicians should weigh the risks versus the benefits when prescribing paliperidone to patients with Parkinson's Disease or Dementia with Lewy Bodies (DLB) since both groups may be at increased risk of Neuroleptic Malignant Syndrome as well as having an increased sensitivity to antipsychotics.

Manifestation of this increased sensitivity can include confusion, obtundation, postural instability with frequent falls, in addition to extrapyramidal symptoms.

Priapism

Antipsychotic medicinal products (including risperidone) with alpha-adrenergic blocking effects have been reported to induce priapism. During post-marketing surveillance, priapism has also been reported with oral paliperidone, which is the active metabolite of risperidone. Patients should be informed to seek urgent medical care in case that priapism has not been resolved within 4 hours.

Body temperature regulation

Disruption of the body's ability to reduce core body temperature has been attributed to antipsychotic medicinal products. Appropriate care is advised when prescribing paliperidone to patients who will be experiencing conditions which may contribute to an elevation in core body temperature, e.g., exercising strenuously, exposure to extreme heat, receiving concomitant medicinal products with anticholinergic activity or being subject to dehydration.

Venous thromboembolism

Cases of venous thromboembolism (VTE) have been reported with antipsychotic medicinal products. Since patients treated with antipsychotics often present with acquired risk factors for VTE, all possible risk factors for VTE should be identified before and during treatment with paliperidone and preventative measures undertaken.

Antiemetic effect

An antiemetic effect was observed in preclinical studies with paliperidone. This effect, if it occurs in humans, may mask the signs and symptoms of overdosage with certain medicinal products or of conditions such as intestinal obstruction, Reye's syndrome and brain tumour.

Administration

Care must be taken to avoid inadvertent injection of Paliperidone STADA into a blood vessel.

Intraoperative Floppy Iris Syndrome

Intraoperative floppy iris syndrome (IFIS) has been observed during cataract surgery in patients treated with medicinal products with alpha 1a-adrenergic antagonist effect, such as paliperidone (see section 4.8).

IFIS may increase the risk of eye complications during and after the operation. Current or past use of medicinal products with alpha 1a-adrenergic antagonist effect should be made known to the ophthalmic surgeon in advance of surgery. The potential benefit of stopping alpha 1 blocking therapy prior to cataract surgery has not been established and must be weighed against the risk of stopping the antipsychotic therapy.

Excipients

This medicinal product contains less than 1 mmol sodium (23 mg) per dosage unit, that is to say essentially sodium-free.

4.5. Interaction with other medicinal products and other forms of interaction

Caution is advised when prescribing paliperidone with medicinal products known to prolong the QT interval, e.g. class IA antiarrhythmics (e.g., quinidine, disopyramide) and class III antiarrhythmics (e.g. amiodarone, sotalol), some antihistaminics, some other antipsychotics and some antimalarials (e.g. mefloquine). This list is indicative and not exhaustive.

Potential for paliperidone to affect other medicines

Paliperidone is not expected to cause clinically important pharmacokinetic interactions with medicinal products that are metabolised by cytochrome P-450 isozymes.

Given the primary central nervous system (CNS) effects of paliperidone (see section 4.8), paliperidone should be used with caution in combination with other centrally acting medicinal products, e.g., anxiolytics, most antipsychotics, hypnotics, opiates, etc. or alcohol.

Paliperidone may antagonise the effect of levodopa and other dopamine agonists. If this combination is deemed necessary, particularly in end-stage Parkinson's disease, the lowest effective dose of each treatment should be prescribed.

Because of its potential for inducing orthostatic hypotension (see section 4.4), an additive effect may be observed when paliperidone is administered with other therapeutic agents that have this potential, e.g., other antipsychotics, tricyclics.

Caution is advised if paliperidone is combined with other medicinal products known to lower the seizure threshold (i.e., phenothiazines or butyrophenones, tricyclics or SSRIs, tramadol, mefloquine, etc.).

Co-administration of oral paliperidone prolonged release tablets at steady-state (12 mg once daily) with divalproex sodium prolonged release tablets (500 mg to 2,000 mg once daily) did not affect the steady-state pharmacokinetics of valproate.

No interaction study between paliperidone and lithium has been performed, however, a pharmacokinetic interaction is not likely to occur.

Potential for other medicines to affect paliperidone

In vitro studies indicate that CYP2D6 and CYP3A4 may be minimally involved in paliperidone metabolism, but there are no indications in vitro nor in vivo that these isozymes play a significant role in the metabolism of paliperidone. Concomitant administration of oral paliperidone with paroxetine, a potent CYP2D6 inhibitor, showed no clinically significant effect on the pharmacokinetics of paliperidone.

Co-administration of oral paliperidone prolonged release once daily with carbamazepine 200 mg twice daily caused a decrease of approximately 37 % in the mean steady-state Cmax and AUC of paliperidone.

This decrease is caused, to a substantial degree, by a 35 % increase in renal clearance of paliperidone likely as a result of induction of renal P-gp by carbamazepine. A minor decrease in the amount of active substance excreted unchanged in the urine suggests that there was little effect on the CYP metabolism or bioavailability of paliperidone during carbamazepine co-administration. Larger decreases in plasma concentrations of paliperidone could occur with higher doses of carbamazepine. On initiation of carbamazepine, the dose of paliperidone should be re-evaluated and increased if necessary.

Conversely, on discontinuation of carbamazepine, the dose of paliperidone should be re-evaluated and decreased if necessary.

Co-administration of a single dose of an oral paliperidone prolonged release tablet 12 mg with divalproex sodium prolonged release tablets (two 500 mg tablets once daily) resulted in an increase of approximately 50 % in the Cmax and AUC of paliperidone, likely as a result of increased oral absorption. Since no effect on the systemic clearance was observed, a clinically significant interaction would not be expected between divalproex sodium prolonged release tablets and paliperidone intramuscular injection. This interaction has not been studied with paliperidone.

Concomitant use of paliperidone with risperidone or with oral paliperidone

Since paliperidone is the major active metabolite of risperidone, caution should be exercised when paliperidone is co-administered with risperidone or with oral paliperidone for extended periods of time.

Safety data involving concomitant use of paliperidone with other antipsychotics is limited.

Concomitant use of paliperidone with psychostimulants

The combined use of psychostimulants (e.g., methylphenidate) with paliperidone can lead to extrapyramidal symptoms upon change of either or both treatments (see section 4.4).

4.6. Fertility, pregnancy and lactation

Pregnancy

There are no adequate data from the use of paliperidone during pregnancy. Intramuscularly injected paliperidone palmitate and orally administered paliperidone were not teratogenic in animal studies, but other types of reproductive toxicity were seen (see section 5.3). Neonates exposed to paliperidone during the third trimester of pregnancy are at risk of adverse reactions including extrapyramidal and/or withdrawal symptoms that may vary in severity and duration following delivery. There have been reports of agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, or feeding disorder. Consequently, newborns should be monitored carefully. Paliperidone should not be used during pregnancy unless clearly necessary.

Breast-feeding

Paliperidone is excreted in the breast milk to such an extent that effects on the breast-fed infant are likely if therapeutic doses are administered to breast-feeding women. Paliperidone should not be used while breast-feeding.

Fertility

There were no relevant effects observed in the non-clinical studies.

4.7. Effects on ability to drive and use machines

Paliperidone can have minor or moderate influence on the ability to drive and use machines due to potential nervous system and visual effects, such as sedation, somnolence, syncope, vision blurred (see section 4.8). Therefore, patients should be advised not to drive or operate machines until their individual susceptibility to paliperidone is known.

4.8. Undesirable effects

Summary of the safety profile

The adverse reactions most frequently reported in clinical trials were insomnia, headache, anxiety, upper respiratory tract infection, injection site reaction, parkinsonism, weight increased, akathisia, agitation, sedation/somnolence, nausea, constipation, dizziness, musculoskeletal pain, tachycardia, tremor, abdominal pain, vomiting, diarrhoea, fatigue, and dystonia. Of these, akathisia and sedation/somnolence appeared to be dose-related.

Tabulated list of adverse reactions

The following are all adverse reactions that were reported with paliperidone by frequency category estimated from paliperidone palmitate clinical trials. The following terms and frequencies are applied: very common (≥ 1/10); common (≥ 1/100 to < 1/10); uncommon (≥ 1/1,000 to < 1/100); rare (≥ 1/10,000 to < 1/1,000); very rare (< 1/10,000); and not known (cannot be estimated from the available data).

System Organ Class

Adverse Drug Reaction

Frequency

Very common

Common

Uncommon

Rare

Not knowna

Infections and infestations

Upper respiratory tract infection, urinary tract infection, influenza.

Pneumonia, bronchitis, respiratory tract infection, sinusitis, cystitis, ear infection, tonsillitis, onychomycosis, cellulitis, subcutaneous abscess.

Eye infection, acarodermatitis.

Blood and lymphatic system disorders

White blood cell count decreased, anaemia.

Neutropenia, thrombocytopenia, eosinophil count increased.

Agranulocytosis.

Immune system disorders

Hypersensitivity.

Anaphylactic reaction.

Endocrine disorders

Hyperprolactinaemiab.

Inappropriate antidiuretic hormone secretion, glucose urine present

Metabolism and nutrition disorders

Hyperglycaemia, weight increased, weight decreased, decreased appetite.

Diabetes mellitusd, hyperinsulinaemia, increased appetite, anorexia, blood triglycerides increased, blood cholesterol increased.

Diabetic ketoacidosis, hypoglycaemia, polydipsia.

Water intoxication.

Psychiatric disorders

Insomniae.

Agitation, depression, anxiety.

Sleep disorder, mania, libido decreased, nervousness, nightmare.

Catatonia, confusional state, somnambulism, blunted affect, anorgasmia.

Sleep-related eating disorder.

Nervous system disorders

Parkinsonismc, akathisiac, sedation/somnolence, dystoniac, dizziness, dyskinesiac, tremor, headache.

Tardive dyskinesia, syncope, psychomotor hyperactivity, dizziness postural, disturbance in attention, dysarthria, dysgeusia, hypoaesthesia, paraesthesia.

Neuroleptic malignant syndrome, cerebral ischaemia, unresponsive to stimuli, loss of consciousness, depressed level of consciousness, convulsione, balance disorder, coordination abnormal, head titubation.

Diabetic coma.

Eye disorders

Vision blurred, conjunctivitis, dry eye.

Glaucoma, eye movement disorder, eye rolling, photophobia, lacrimation increased, ocular hyperaemia.

Floppy iris syndrome (intraoperative).

Ear and labyrinth disorders

Vertigo, tinnitus, ear pain.

Cardiac disorders

Tachycardia.

Atrioventricular block, conduction disorder, electrocardiogram QT prolonged, postural orthostatic tachycardia syndrome, bradycardia, electrocardiogram abnormal, palpitations.

Atrial fibrillation, sinus arrhythmia

Vascular disorders

Hypertension.

Hypotension, orthostatic hypotension.

Pulmonary embolism, venous thrombosis, flushing.

Ischaemia.

Respiratory, thoracic and mediastinal disorders

Cough, nasal congestion.

Dyspnoea, pharyngolaryngeal pain, epistaxis.

Sleep apnoea syndrome, pulmonary congestion, respiratory tract congestion, rales, wheezing.

Hyperventilation, pneumonia, aspiration, dysphonia.

Gastrointestinal disorders

Abdominal pain, vomiting, nausea, constipation, diarrhoea, dyspepsia, toothache.

Abdominal discomfort, gastroenteritis, dysphagia, dry mouth, flatulence.

Pancreatitis, intestinal obstruction, swollen tongue, faecal incontinence, faecaloma, cheilitis.

Ileus.

Hepatobiliary disorders

Transaminases increased.

Gamma-glutamyltransferase increased, hepatic enzyme increased.

Jaundice.

Skin and subcutaneous tissue disorders

Urticaria, pruritus, rash, alopecia, eczema, dry skin, erythema, acne

Drug eruption, hyperkeratosis, seborrhoeic dermatitis, dandruff.

Stevens-Johnson syndrome/toxic epidermal necrolysis, angioedema, skin discolouration..

Musculoskeletal and connective tissue disorders

Musculoskeletal pain, back pain, arthralgia.

Blood creatine phosphokinase increased, muscle spasms, joint stiffness, muscular weakness.

Rhabdomyolysis, joint swelling.

Posture abnormal.

Renal and urinary disorders

Urinary incontinence, pollakiuria, dysuria

Urinary retention.

Pregnancy, puerperium and perinatal condition

Drug withdrawal syndrome neonatal (see section 4.6).

Reproductive system and breast disorders

Amenorrhoea.

Erectile dysfunction, ejaculation disorder, menstrual disordere, gynaecomastia, galactorrhoea, sexual dysfunction, breast pain.

Priapism, breast discomfort, breast engorgement, breast enlargement, vaginal discharge.

General disorders and administration site conditions

Pyrexia, asthenia, fatigue, injection site reaction

Face oedema, oedemae, body temperature increased, gait abnormal, chest pain, chest discomfort, malaise, induration.

Hypothermia, chills, thirst, drug withdrawal syndrome, injection site abscess, injection site cellulitis, injection site cyst, injection site haematoma.

Body temperature decreased, injection site necrosis, injection site ulcer.

Injury, poisoning and procedural complications

Fall.

a The frequency of these adverse reactions is qualified as “not known” because they were not observed in paliperidone palmitate clinical trials. They were either derived from spontaneous post-marketing reports and frequency cannot be determined, or they were derived from risperidone (any formulation) or oral paliperidone clinical trials data and/or post-marketing reports.

b Refer to 'Hyperprolactinaemia' below.

c Refer to 'Extrapyramidal symptoms' below.

d In placebo-controlled trials, diabetes mellitus was reported in 0.32 % in paliperidone-treated subjects compared to a rate of 0.39 % in placebo group. Overall incidence from all clinical trials was 0.65 % in all paliperidone palmitate -treated subjects

e Insomnia includes: initial insomnia, middle insomnia; Convulsion includes: grand mal convulsion; Oedema includes: generalised oedema, oedema peripheral, pitting oedema. Menstrual disorder includes: menstruation delayed, menstruation irregular, oligomenorrhoea.

Undesirable effects noted with risperidone formulations

Paliperidone is the active metabolite of risperidone, therefore, the adverse reaction profiles of these compounds (including both the oral and injectable formulations) are relevant to one another.

Description of selected adverse reactions

Anaphylactic reaction

Rarely, cases of anaphylactic reaction after injection with paliperidone have been reported during post-marketing experience in patients who have previously tolerated oral risperidone or oral paliperidone (see section 4.4).

Injection site reactions

The most commonly reported injection site related adverse reaction was pain. The majority of these reactions were reported to be of mild to moderate severity. Subject evaluations of injection site pain based on a visual analogue scale tended to lessen in frequency and intensity over time in all Phase 2 and 3 studies with paliperidone. Injections into the deltoid were perceived as slightly more painful than corresponding gluteal injections. Other injection site reactions were mostly mild in intensity and included induration (common), pruritus (uncommon) and nodules (rare).

Extrapyramidal symptoms (EPS)

EPS included a pooled analysis of the following terms: parkinsonism (includes salivary hypersecretion, musculoskeletal stiffness, parkinsonism, drooling, cogwheel rigidity, bradykinesia, hypokinesia, masked facies, muscle tightness, akinesia, nuchal rigidity, muscle rigidity, parkinsonian gait, glabellar reflex abnormal, and parkinsonian rest tremor), akathisia (includes akathisia, restlessness, hyperkinesia, and restless leg syndrome), dyskinesia (dyskinesia, muscle twitching, choreoathetosis, athetosis, and myoclonus), dystonia (includes dystonia, hypertonia, torticollis, muscle contractions involuntary, muscle contracture, blepharospasm, oculogyration, tongue paralysis, facial spasm, laryngospasm, myotonia, opisthotonus, oropharyngeal spasm, pleurothotonus, tongue spasm, and trismus), and tremor. It should be noted that a broader spectrum of symptoms are included that do not necessarily have an extrapyramidal origin.

Weight gain

In the 13-week study involving the 150 mg initiation dosing, the proportion of subjects with an abnormal weight increase ≥ 7 % showed a dose-related trend, with a 5 % incidence rate in the placebo group compared with rates of 6 %, 8 % and 13 % in the paliperidone 25 mg, 100 mg, and 150 mg groups, respectively.

During the 33-week open-label transition/maintenance period of the long-term recurrence prevention trial, 12 % of paliperidone-treated subjects met this criterion (weight gain of ≥ 7 % from double-blind phase to endpoint); the mean (SD) weight change from open-label baseline was + 0.7 (4.79) kg.

Hyperprolactinaemia

In clinical trials, median increases in serum prolactin were observed in subjects of both genders who received paliperidone. Adverse reactions that may suggest increase in prolactin levels (e.g., amenorrhoea, galactorrhoea, menstrual disturbances, gynaecomastia) were reported overall in < 1 % of subjects.

Class effects

QT prolongation, ventricular arrhythmias (ventricular fibrillation, ventricular tachycardia), sudden unexplained death, cardiac arrest, and Torsade de pointes may occur with antipsychotics.

Cases of venous thromboembolism, including cases of pulmonary embolism and cases of deep vein thrombosis, have been reported with antipsychotic medicinal products (frequency unknown).

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme website: www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in the Google Play or Apple App Store.

4.9. Overdose

Symptoms

In general, expected signs and symptoms are those resulting from an exaggeration of paliperidone's known pharmacological effects, i.e., drowsiness and sedation, tachycardia and hypotension, QT prolongation, and extrapyramidal symptoms. Torsade de pointes and ventricular fibrillation have been reported in a patient in the setting of overdose with oral paliperidone. In the case of acute overdose, the possibility of multiple drug involvement should be considered.

Management

Consideration should be given to the prolonged release nature of the medicinal product and the long elimination half-life of paliperidone when assessing treatment needs and recovery. There is no specific antidote to paliperidone. General supportive measures should be employed. Establish and maintain a clear airway and ensure adequate oxygenation and ventilation.

Cardiovascular monitoring should commence immediately and should include continuous electrocardiographic monitoring for possible arrhythmias. Hypotension and circulatory collapse should be treated with appropriate measures such as intravenous fluid and/or sympathomimetic agents. In case of severe extrapyramidal symptoms, anticholinergic agents should be administered. Close supervision and monitoring should continue until the patient recovers.