07 2014 Psychotherapeutic Agents- Paliperidone

Peak Development for ...
Medication Administration
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Vol. 15 Issue 7
July 2014
Psychotherapeutic Agents:
Paliperidone (Invega)
Peak Development Resources
P.O. Box 13267
Richmond, VA 23225

Phone: (804) 233-3707
Fax: (804) 233-3705
Email: [email protected]
After completion the learner should be able to:
1. Identify appropriate indications for use of
paliperidone.
2. Relate general characteristics of
paliperidone to specific patient situations.
3. Apply nursing process considerations for
paliperidone to specific patient situations.

Schizophrenia
Schizophrenia is a chronic psychotic
disorder of unknown etiology, affecting
approximately 1% of Americans. It is usually
first diagnosed in adolescence or early
adulthood and is characterized by acute
psychotic episodes, followed by periods of
remission. Acute episodes are characterized by
delusions, auditory and/or visual hallucinations,
disorganized thought processes, inappropriate
emotional responses, labile mood and poor self
-care. As acute symptoms subside, patients
may exhibit less intense symptoms, such as
suspiciousness, poor judgment, decreased
capacity for self-care and diminished
motivation. There is increased risk for suicide.
Schizophrenic patients have difficulty
establishing and maintaining relationships,
stable employment and independent
functioning. Compliance with treatment can be
problematic, as patients may stop taking their
medication due to side effects, cost, or
believing that they do not have a disorder.
The first antipsychotic drugs were the
phenothiazines, such as chlorpromazine
(Thorazine). These were developed in the
1950’s, and were the mainstay of treatment for
schizophrenia until the atypical antipsychotics,
such as clozapine (Clozaril) and risperidone
(Risperdal), were developed, starting in 1989.
The phenothiazines have been largely
discontinued, due to risk of adverse effects and
the development of safer and more effective
drugs. One of the more serious adverse effects
with this group was the occurrence of
extrapyramidal symptoms, movement disorders
that may cause restlessness, muscle spasms,
tremors, parkinsonism, and tardive dyskinesia.
The atypical agents currently in use, also
called second-generation antipsychotics, have
a lower risk of producing EPS. They can also
improve both positive and negative symptoms
of schizophrenia, while phenothiazines tended
to treat mainly the positive symptoms. Positive
symptoms (exaggeration of normal responses)
include hallucinations, delusions, paranoia and
agitation. Negative symptoms (loss of normal
responses) include flat affect, poor self-care,
lack of motivation, and social withdrawal.

Paliperidone
Paliperidone, brand name Invega, is a
second-generation antipsychotic agent
approved by the FDA in 2006.
Indications
Paliperidone (Invega) is an extended-
release oral medication, indicated for the
treatment of schizophrenia in adults and
adolescents ages 12-17. It is also approved for
the treatment of schizoaffective disorder in
adults. Invega Sustenna is an intramuscular
suspension approved for the treatment of
schizophrenia in adults.
Pharmacodynamics
The exact mechanism of action is
unknown, but is thought to involve blocking of
specific receptors for dopamine and serotonin.
Pharmacokinetics
Absorpt i on: Oral absorption and
bioavailability are relatively low; serum levels
are increased when administered with food; for
the intramuscular form, injection into the deltoid
results in faster absorption and higher serum
levels compared to gluteal injection
Distribution: Moderately protein-bound; well-
distributed throughout body tissues, crosses the
blood-brain barrier and is excreted in breast
milk
Metabolism: Undergoes very little
metabolism; most of the drug is excreted
unchanged.
Elimination: The majority is excreted
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individual facility only. Sharing
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entity is expressly prohibited.
The information contained in
Peak Development for… Medication
Administration is intended only as
a guide for the practice of
licensed nursing personnel who
administer medications. Every
effort has been made to verify the
accuracy of the information
herein. Because of rapid changes
in the field of drug therapy, the
reader is advised to consult the
package insert, facility pharmacist
or patient’s physician for relevant
information. This is particularly
important for new or seldom used
drugs. Use of professional
judgment is required in all patient
care situations. It is the reader’s
responsibility to understand and
adhere to policies and procedures
set forth by the employing
institution. The editor and
publisher of this newsletter
disclaim any liability resulting
from use or misuse of
information contained herein.

Copyright © 2014
unchanged in the urine; a small amount of drug is excreted in
the stool
Major Interactions
Levodopa and other dopamine agonists: Paliperidone
blocks dopamine receptors, reducing the effects of these drugs
Alcohol and CNS depressant drugs: May cause additive
CNS depressant effect
Carbamazine: May increase clearance of paliperidone,
reducing its serum levels; increased dosage of paliperidone
may be required
Antihypertensive medications: May increase the
hypotensive effects of paliperidone
Drugs known to prolong the Q-T interval, such as
quinidine, amiodarone, moxifloxacin and erythromycin: May
increase the risk of torsades de pointes and sudden death
Adverse Effects/Toxicity
Common adverse effects of paliperidone include
headache, GI upset, blurred vision, dry mouth and drowsiness.
Orthostatic hypotension and dizziness may occur. The seizure
threshold may be lowered, increasing the risk of seizures. The
QT interval may be prolonged, increasing the risk of sudden
death. White blood cell production may decrease, increasing
the risk of infection. Hyperprolactinemia may occur, causing
breast enlargement and milk production in males and females.
There is risk of difficulty swallowing and aspiration pneumonia,
and hyperthermia due to changes in temperature regulation.
Possible metabolic effects include hyperglycemia,
changes in blood lipids and weight gain. Extrapyramidal
symptoms and neuroleptic malignant syndrome (NMS) may
occur. NMS is a rare but serious complication that can result in
death. Signs and symptoms include fever, severe muscle
rigidity, agitation, confusion, dysrhythmias, and respiratory and
renal failure. Paliperidone has a boxed warning for increased
death risk in elderly patients with dementia-related psychosis.
Precautions/Contraindications
Use cautiously in patients with a history of seizures,
cardiovascular disease or diabetes, and those at risk for
aspiration pneumonia. Dosage should be reduced in patients
with moderate to severe renal impairment. Contraindicated for
use in elderly patients with dementia-related psychosis.
Nursing Process
Assessment
Determine baseline status: A complete physical and
mental status exam should be performed to document
baseline status. Diagnostic tests for renal, cardiac and
metabolic function should be reviewed for abnormalities. WBC
counts should be reviewed before treatment and repeated
periodically to monitor for leukopenia. Blood pressure should
be measured lying, sitting and standing to detect postural
hypotension. Assess for signs and symptoms of acute
psychosis and document the patient's behavior, emotional
state, cognitive ability and relationship to the current
environment.
Identify risk factors: Assess patient for conditions that
increase risk, such as diabetes, bone marrow suppression,
cardiovascular disease, dysphagia or seizure disorder.
Age-specific considerations: FDA pregnancy category C.
Paliperidone should be used by nursing mothers only if the
benefit outweighs the potential risk. Safety and efficacy for use
in children younger than 12 years are not established. Some
elderly patients may be at increased risk for adverse effects,
such as confusion and sedation.
Planning and Analysis
The goals of treatment are to prevent acute psychotic
episodes, promote optimal functioning in activities of daily
living, and prevent or shorten hospitalizations.
Intervention
Medication administration: The tablet should be given
whole, and not broken, crushed or chewed, as it is extended-
release. The tablet shell does not disintegrate, and may
appear in the stool. It may be administered with or without
food, although taking it with food may increase serum levels.
The IM injectable form should be administered in the deltoid
muscle for the first two doses, one week apart, for most rapid
effect. After that, doses are administered monthly, and may be
injected into the gluteal or deltoid muscles.
Observe for therapeutic effects: Desired effects include
decreased delusions, hallucinations, hostility and hyperactivity,
and increased socialization, self-care, judgment, and
participation in therapeutic activities.
Observe for adverse effects: The CBC should be
monitored for leukopenia regularly, particularly in the first few
months, and treatment stopped if a decrease in the white
blood cell count occurs. Ongoing monitoring for diabetes,
abnormal movements, cardiovascular effects, hypotension,
and suicide risk is important throughout therapy.
Patient/Family teaching:
 Take medication as prescribed, and keep all appointments.
 Improvement in symptoms may take several weeks.
 Do not break, crush or chew the tablet.
 The tablet shell may be visible in stool—this is normal.
 Take measures to prevent overheating and dehydration.
 Change positions and stand slowly to prevent falls from
hypotension, until drug effects are known.
 Avoid driving or operating dangerous equipment until drug
effects are known.
 Do not drink alcohol or take any prescription or over-the-
counter (OTC) medication without contacting the doctor.
 Notify the doctor of fever, sore throat, uncontrollable
movements, tremors or suicidal thoughts.
 Do not discontinue the drug without talking with the doctor.
Evaluation
Through careful monitoring and education, the nurse can
promote safe and effective treatment for the patient taking
paliperidone.
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Psychotherapeutic Agents: Paliperidone Page 2
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Competency Assessment Tool
Vol. 15 Issue 7
July 2014
Psychotherapeutic Agents:
Paliperidone (Invega)
Directions: Place the letter of the one best answer in the space provided.
NAME: DATE:
_____1. Schizophrenia is most commonly first diagnosed in which age group:
A. children under the age of 10
B. adolescents and young adults
C. middle-aged adults
D. adults age 65 and older

_____2. Which of the following is most clearly a component of schizophrenia:
A. depression
B. narcissism
C. psychosis
D. anxiety

_____3. Negative symptoms of schizophrenia include:
A. auditory hallucinations
B. agitation
C. paranoia
D. social withdrawal

_____4. Paliperidone (Invega) oral tablets are approved for use in:
A. adults with schizophrenia
B. adolescents aged 12-17 with schizophrenia
C. adults with schizoaffective disorder
D. all of the above

_____5. Invega Sustenna, the injectable form of paliperidone, is approved for use only in adults with
schizophrenia.
A. True
B. False


UNIT:
Competency Assessment Tool
Psychotherapeutic Agents: Paliperidone
Page 2
_____6. Invega Sustenna is approved for administration by which of the following routes:
A. intramuscular
B. intravenous
C. subcutaneous
D. intravenous and intramuscular

_____7. For most rapid effects, the injectable form of paliperidone should be administered into the:
A. thigh
B. upper arm
C. buttock
D. abdomen

_____8. Shortly after starting to take paliperidone, a patient experiences restlessness and tremors.
These are most likely to be which of the following:
A. signs of insufficient dosage
B. signs of infection
C. extrapyramidal symptoms
D. common symptoms of schizophrenia

_____9. Paliperidone carries a boxed warning that it should not be administered to:
A. patients who have diabetes
B. adults or adolescents with a history of seizures
C. patients taking other drugs with CNS depressant effects
D. elderly patients with dementia-related psychosis

_____10. Teaching for a patient starting on paliperidone should include all of the following EXCEPT:
A. do not break, crush or chew the tablet
B. take measures to prevent overheating and dehydration
C. call the doctor if benefits are not seen in 3-5 days
D. change position slowly to prevent dizziness and falls

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Month: July 2014
Issue: Psychotherapeutic Agents:
Paliperidone
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