4.1. Therapeutic indications

TREVICTA, a 3-monthly injection, is indicated for the maintenance treatment of schizophrenia in adult patients who are clinically stable on 1-monthly paliperidone palmitate injectable product (see section 5.1).

4.2. Posology and method of administration

Posology

Patients who are adequately treated with 1-monthly paliperidone palmitate injectable (preferably for four months or more) and do not require dose adjustment may be switched to 3-monthly paliperidone palmitate injection.

TREVICTA should be initiated in place of the next scheduled dose of 1-monthly paliperidone palmitate injectable (± 7 days). The TREVICTA dose should be based on the previous 1-monthly paliperidone palmitate injectable dose using a 3.5-fold higher dose shown in the following table:

TREVICTA doses for patients adequately treated with 1-monthly paliperidone palmitate injectable

If the last dose of 1-monthly paliperidone palmitate injectable is

Initiate TREVICTA at the following dose

50 mg

175 mg

75 mg

263 mg

100 mg

350 mg

150 mg

525 mg

There is no equivalent dose of TREVICTA for the 25 mg dose of 1-monthly paliperidone palmitate injectable which was not studied.

Following the initial TREVICTA dose, TREVICTA should be administered by intramuscular injection once every 3 months (± 2 weeks, see also Missed dose section).

If needed, dose adjustment of TREVICTA can be made every 3 months in increments within the range of 175 mg to 525 mg based on individual patient tolerability and/or efficacy. Due to the long-acting nature of TREVICTA, the patient's response to an adjusted dose may not be apparent for several months (see section 5.2). If the patient remains symptomatic, they should be managed according to clinical practice.

Switching from other antipsychotic medicinal products

Patients should not be switched directly from other antipsychotics as 3-monthly paliperidone palmitate injectable should only be initiated after the patient is stabilised on the 1-monthly paliperidone palmitate injectable.

Switching from TREVICTA to other antipsychotic medicinal products

If TREVICTA is discontinued, its prolonged release characteristics must be considered.

Switching from TREVICTA to 1-monthly paliperidone palmitate injectable

For switching from TREVICTA to 1-monthly paliperidone palmitate injectable, 1-monthly paliperidone palmitate injectable should be administered at the time the next TREVICTA dose was to be administered using a 3.5-fold lower dose shown in the following table. The initiation dosing as described in the prescribing information for 1-monthly paliperidone palmitate injectable is not required. The 1-monthly paliperidone palmitate injectable should then continue to be dosed at monthly intervals as described within its prescribing information.

Doses of 1-monthly paliperidone palmitate injectable for patients switching from TREVICTA

If the last dose of TREVICTA is

Initiate 1-monthly paliperidone palmitate injectable 3 months later at the following dose

175 mg

50 mg

263 mg

75 mg

350 mg

100 mg

525 mg

150 mg

Switching from TREVICTA to oral daily paliperidone prolonged release tablets

For switching from TREVICTA to paliperidone prolonged release tablets, the daily dosing of paliperidone prolonged release tablets should be started 3 months after the last TREVICTA dose and treatment continued with paliperidone prolonged release tablets as described in the table below. The following table provides recommended dose conversion regimens to allow patients previously stabilised on different doses of TREVICTA to attain similar paliperidone exposure with paliperidone prolonged release tablets.

Doses of paliperidone prolonged release tablets for patients switching from TREVICTA*

Last TREVICTA dose (Week 0)

Week number after last TREVICTA dose

Week 12 to Week 18, inclusive

Week 19 to Week 24, inclusive

From Week 25 onwards

Daily dose of paliperidone prolonged release tablets

175 mg

3 mg

3 mg

3 mg

263 mg

3 mg

3 mg

6 mg

350 mg

3 mg

6 mg

9 mg

525 mg

6 mg

9 mg

12 mg

* All doses of once daily paliperidone prolonged release tablets should be individualised to the specific patient, taking into consideration variables such as reasons for switching, response to previous paliperidone treatment, severity of psychotic symptoms, and/or propensity for side effects.

Missed dose

Dosing window

TREVICTA should be injected once every 3 months. To avoid a missed dose of TREVICTA patients may be given the injection up to 2 weeks before or after the 3-month time point.

Missed doses

If scheduled dose is missed and the time since last injection is

Action

> 3½ months up to 4 months

The injection should be administered as soon as possible and then resume the 3-monthly injection schedule.

4 months to 9 months

Use the recommended re-initiation regimen shown in the table below.

> 9 months

Re-initiate treatment with 1-monthly paliperidone palmitate injectable as described in the prescribing information for that product. TREVICTA can then be resumed after the patient has been adequately treated with 1-monthly paliperidone palmitate injectable preferably for four months or more.

Recommended re-initiation regimen after missing 4 months to 9 months of TREVICTA

If the last dose of TREVICTA was

Administer 1-monthly paliperidone palmitate injectable, two doses one week apart (into deltoid muscle)

Then administer TREVICTA (into deltoida or gluteal muscle)

Day 1

Day 8

1 month after day 8

175 mg

50 mg

50 mg

175 mg

263 mg

75 mg

75 mg

263 mg

350 mg

100 mg

100 mg

350 mg

525 mg

100 mg

100 mg

525 mg

a See also Information intended for medical or healthcare professionals for deltoid injection needle selection based on body weight.

Special populations

Elderly

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

In general, recommended dosing of TREVICTA for elderly patients with normal renal function is the same as for younger adult patients with normal renal function. As elderly patients may have reduced renal function, see Renal impairment below for dosing recommendations in patients with renal impairment.

Renal impairment

TREVICTA has not been studied in patients with renal impairment (see section 5.2). For patients with mild renal impairment (creatinine clearance ≥ 50 to < 80 mL/min), dose should be adjusted and the patient stabilised using 1-monthly paliperidone palmitate injectable, and then transitioned to TREVICTA.

TREVICTA is not recommended in patients with moderate or severe renal impairment (creatinine clearance < 50 mL/min).

Hepatic impairment

TREVICTA has not been studied in patients with 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 TREVICTA in children and adolescents < 18 years of age have not been established. No data are available.

Method of administration

TREVICTA is intended for intramuscular use only. It must not be administered by any other route. Each injection must be administered only by a health-care professional giving the full dose in a single injection. It should be injected slowly, deep into the deltoid or gluteal muscle. A switch from gluteal to deltoid (and vice versa) should be considered for future injection in the event of injection site discomfort (see section 4.8).

TREVICTA must be administered using only the thin wall needles that are provided in the TREVICTA pack. Needles from the 1-monthly paliperidone palmitate injectable pack or other commercially available needles must not be used when administering TREVICTA (see Information intended for medical or health-care professionals).

The contents of the pre-filled syringe should be inspected visually for foreign matter and discolouration prior to administration. It is important to shake the syringe vigorously with the tip up and a loose wrist for at least 15 seconds to ensure a homogeneous suspension. TREVICTA should be administered within 5 minutes after shaking. If more than 5 minutes pass before injection, shake vigorously again for at least 15 seconds to re-suspend the medicinal product. (See Information intended for medical or health-care professionals).

Deltoid muscle administration

The specified needle for administration of TREVICTA into the deltoid muscle is determined by the patient's weight.

• For those ≥ 90 kg, the thin wall 1½ inch, 22 gauge (0.72 mm x 38.1 mm) needle should be used.

• For those < 90 kg, the thin wall 1 inch, 22 gauge (0.72 mm x 25.4 mm) needle should be used.

It should be administered into the centre of the deltoid muscle. Deltoid injections should be alternated between the two deltoid muscles.

Gluteal muscle administration

The needle to be used for administration of TREVICTA into the gluteal muscle is the thin wall 1½ inch, 22 gauge (0.72 mm x 38.1 mm) needle regardless of body weight. It should be administered into the upper-outer quadrant of the gluteal muscle. Gluteal injections should be alternated between the two gluteal muscles.

Incomplete administration

To avoid incomplete administration of TREVICTA, the pre-filled syringe must be shaken vigorously for at least 15 seconds within 5 minutes prior to administration to ensure a homogeneous suspension (see Information intended for medical or health-care professionals).

However, in the event of an incompletely injected dose, the dose remaining in the syringe should not be re-injected and another dose should not be given since it is difficult to estimate the proportion of the dose actually administered. The patient should be closely monitored and managed as clinically appropriate until the next scheduled 3-monthly injection of TREVICTA.

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

TREVICTA 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. Consideration should be given to the long-acting nature of TREVICTA.

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. Consideration should be given to the long-acting nature of TREVICTA.

Caution is warranted in patients receiving both, psychostimulants (e.g., methylphenidate) and paliperidone concomitantly, as extrapyramidal symptoms could emerge when adjusting one or both medicinal products. 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. 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 TREVICTA 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 < 1 x 109/L) should discontinue TREVICTA and have their WBC followed until recovery. Consideration should be given to the long-acting nature of TREVICTA.

Hypersensitivity reactions

Hypersensitivity reactions can occur even in patients who have previously tolerated oral risperidone or oral paliperidone (see section 4.8).

Hyperglycaemia and diabetes mellitus

Hyperglycaemia, diabetes mellitus, and exacerbation of pre-existing diabetes, including diabetic coma and ketoacidosis, have been reported with paliperidone. Appropriate clinical monitoring is advisable in accordance with utilised antipsychotic guidelines. Patients treated with TREVICTA 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 TREVICTA 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-adrenergic blocking activity. In the clinical trials of TREVICTA, 0.3% of subjects reported orthostatic hypotension related adverse reaction. TREVICTA 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

TREVICTA 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. For patients with mild renal impairment (creatinine clearance ≥ 50 mL/min to < 80 mL/min), dose should be adjusted and the patient stabilised using 1-monthly paliperidone palmitate injectable, then transitioned to TREVICTA. TREVICTA 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

TREVICTA has not been studied in elderly patients with dementia. TREVICTA is not recommended to treat elderly patients with dementia due to increased risk of overall mortality and cerebrovascular adverse reactions.

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 TREVICTA 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 paliperidone) with alpha-adrenergic blocking effects have been reported to induce priapism. 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 TREVICTA 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 TREVICTA 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 TREVICTA 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 TREVICTA (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 dose, i.e., essentially sodium-free.

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

Caution is advised when prescribing TREVICTA 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 antibiotics (e.g., fluoroquinolones), some other antipsychotics and some antimalarials (e.g., mefloquine). This list is indicative and not exhaustive.

Potential for TREVICTA to affect other medicines

Paliperidone is not expected to cause clinically important pharmacokinetic interactions with medicinal products that are metabolised by cytochrome P450 isozymes.

Given the primary central nervous system (CNS) effects of paliperidone (see section 4.8), TREVICTA 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 TREVICTA is administered with other medicinal products 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 TREVICTA and lithium has been performed, however, a pharmacokinetic interaction is not likely to occur.

Potential for other medicines to affect TREVICTA

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 TREVICTA should be re-evaluated and increased if necessary. Conversely, on discontinuation of carbamazepine, the dose of TREVICTA should be re-evaluated and decreased if necessary. Consideration should be given to the long-acting nature of TREVICTA.

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 TREVICTA intramuscular injection. This interaction has not been studied with TREVICTA.

Concomitant use of TREVICTA with risperidone or oral paliperidone

Since paliperidone is the major active metabolite of risperidone, caution should be exercised when TREVICTA is co-administered with risperidone or with oral paliperidone for extended periods of time. Safety data involving concomitant use of TREVICTA with other antipsychotics is limited.

Concomitant use of TREVICTA 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. TREVICTA should not be used during pregnancy unless clearly necessary.

Since paliperidone has been detected in plasma up to 18 months after a single dose of TREVICTA, consideration should be given to the long-acting nature of TREVICTA as maternal exposure to TREVICTA before and during pregnancy may lead to adverse reactions in the newborn child.

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. Since paliperidone has been detected in plasma up to 18 months after a single dose administration of TREVICTA, consideration should be given to the long-acting nature of TREVICTA as breastfed infants may be at risk even from TREVICTA administration long before breast-feeding. TREVICTA 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 TREVICTA is known.

4.8. Undesirable effects

Summary of the safety profile

The most frequently observed adverse reactions reported in ≥ 5% of patients in two double-blind controlled clinical trials of TREVICTA were weight increased, upper respiratory tract infection, anxiety, headache, insomnia, and injection site reaction.

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 reactions

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 conditions

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 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 subjects treated with 1-monthly paliperidone palmitate injectable compared to a rate of 0.39% in placebo group. Overall incidence from all clinical trials was 0.65% in all subjects treated 1-monthly paliperidone palmitate injectable.

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 1-monthly paliperidone palmitate injectable 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

In clinical trials of TREVICTA, 5.3% of subjects reported injection site related adverse reaction. None of these events were serious or led to discontinuation. Based on the investigators' ratings, induration, redness, and swelling were absent or mild in ≥ 95% of the assessments. Subject-rated injection site pain based on a visual analogue scale was low and decreased in intensity over time.

Extrapyramidal symptoms (EPS)

In the clinical trials of TREVICTA, akathisia, dyskinesia, dystonia, parkinsonism, and tremor were reported in 3.9%, 0.8%, 0.9%, 3.6%, and 1.4% of subjects, respectively.

Extrapyramidal symptoms (EPS) included a pooled analysis of the following terms: parkinsonism (includes extrapyramidal disorder, extrapyramidal symptoms, on and off phenomenon, Parkinson's disease, parkinsonian crisis, 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, chorea, movement disorder, muscle twitching, choreoathetosis, athetosis, and myoclonus), dystonia (includes dystonia, cervical spasm, emprosthotonus, oculogyric crisis, oromandibular dystonia, risus sardonicus, tetany, 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.

Weight gain

In the long-term randomised withdrawal study, abnormal increases of ≥ 7% in body weight from double-blind baseline to double-blind end point were reported for 10% subjects in the TREVICTA group and 1% subjects in the placebo group. Conversely, abnormal decreases in body weight (≥ 7%) from double-blind baseline to double-blind end point were reported for 1% subjects in the TREVICTA group and 8% subjects in the placebo group. The mean changes in body weight from double-blind baseline to double-blind end point were +0.94 kg and -1.28 kg for the TREVICTA and placebo groups, respectively.

Hyperprolactinaemia

During the double-blind phase of the long-term randomised withdrawal study, elevations of prolactin to above the reference range (> 13.13 ng/mL in males and > 26.72 ng/mL in females) were noted in a higher percentage of males and females in the TREVICTA group than in the placebo group (9% vs. 3% and 5% vs. 1%, respectively). In the TREVICTA group, the mean change from double-blind baseline to double-blind end point was +2.90 ng/mL for males (vs. -10.26 ng/mL in the placebo group) and +7.48 ng/mL for females (vs. -32.93 ng/mL in the placebo group). One female (2.4%) in the TREVICTA group experienced an adverse reaction of amenorrhea, while no potentially prolactin related adverse reactions were noted among females in the placebo group. There were no potentially prolactin related adverse reactions among males in either group.

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 medical 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: https://yellowcard.mhra.gov.uk/ 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 long-acting 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.