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invega 9 Mg 28 Extended Release Tablets ingredient paliperidone
Pharmacotherapeutic group: Other antipsychotics ATC Code: N05A X13
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Interactions with other medicinal products and other forms of interaction
Care should be taken when prescribing INVEGA with medications that prolong QT interval. INVEGA has the potential to affect other medicines:
Paliperidone is not expected to cause clinically significant pharmacokinetic interactions with drugs metabolized by cytochrome P-450 isoenzymes. In vitro studies in human liver microsomes have shown that it does not significantly inhibit the metabolism of drugs metabolised by cytochrome P450 isoenzymes, including paliperidone, CYP1A2, CYP2A6, CYP2C8 / 9/10, CYP2D6, CYP2E1, CYP3A4 and CYP3A5. Therefore, it is unlikely that paliperidone will significantly inhibit the clearance of drugs metabolized by these metabolic pathways. In vitro studies have shown that paliperidone is not a CYP1A2, 2C19 or 3A4 inducer.
Paliperidone is a weak P-glycoprotein (P-gp) inhibitor at high concentrations. in vivo data are not available and its clinical significance is unknown.
Due to the primer effects on the central nervous system of Paliperidone (see Section 4.8 Undesirable Effects), INVEGA should be used with caution with other centrally acting drugs and alcohol. Paliperidone may antagonize the effects of levodopa and other dopamine agonists.
Because of the potential for inducing orthostatic hypotension (see Section 4.4 Special Use Indications and Precautions, Orthostatic Hypotension), additional effects may be observed when INVEGA is administered in combination with other therapeutic agents having this potential.
Pharmacokinetic interaction between INVEGA and lithium is unlikely.
Simultaneous administration of steady-state INVEGA (12 mg once daily) with extended release divalproex sodium tablets (500 mg to 2000 mg once daily) did not affect valproate's steady-state pharmacokinetics.
Potential for other drugs to affect INVEGA:
Paliperidone is not the substrate of CYP1A2, CYP2A6, CYP2C9, CYP2C19 and CYP3A5. This demonstrates that there is no interaction with inhibitors or inducers of these isoenzymes. Although in vitro studies show that CYP2D6 and CYP3A4 are minimally involved in the metabolism of paliperidone, there is no in vitro or in vivo evidence that these enzymes play a significant role in the metabolism of paliperidone. In vitro studies have shown that paliperidone is a P-gp substrate.
Paliperidone is metabolically limited by CYP2D6 (see Section 5.2). Clinically significant effects on the pharmacokinetics of paliperidone have not been observed in an interaction study with healthy volunteers, in which INVEGA was co-administered with paroxetine, a potent CYP2D6 inhibitor.
Coadministration of INVEGA twice daily with carbamazepine 200 mg per day resulted in a reduction of approximately 37% in the mean steady-state Cmax and EAA values of paliperidone. This decline is due, in part, to a 35% increase in renal clearance of paliperidone as a result of induction of renal P-gp by carbamazepine. The low rate of decline in urinary excretion of unchanged drug suggests that CYP metabolism during coadministration with carbamazepine and the effect on the bioavailability of paliperidone are low. When carbamazepine is started, INVEGA should be reevaluated and increased if necessary. Conversely, when carbamazepine is discontinued, INVEGA should be reevaluated and, if necessary, reduced.
Paliperidone, a cation at physiological pH, is released unchanged mainly from the kidneys, about half by filtration, half by active secretion. Simultaneous administration with trimethoprim, a known drug that inhibits the active passage of cationic drugs from the kidneys, has not affected the pharmacokinetics of paliperidone.
Simultaneous administration of a single dose of 12 mg INVEGA with extended release divalproex sodium tablets (two 500 mg tablets once daily) resulted in an approximately 50% increase in Cmax and EAA of paliperidone. If INVEGA is administered concurrently with valproate after clinical evaluation, reduction of INVEGA dose should be considered.
Pharmacokinetic interaction between INVEGA and lithium is unlikely. Use of INVEGA with risperidone:
4.6. Pregnancy and lactation
Pregnancy Category: C
Women with childbearing potential / Contraception (Contraception)
Paliperidone has not been proven as reliable as human pregnancy.
No teratogenic effects have been reported in animal studies. A slight increase in fetal mortality was observed in laboratory animals treated with high-dose paliperidone. This is toxic for high-dose mothers. Newborns were not affected by 20 to 34 times the highest human dose. INVEGA should not be used during pregnancy unless the benefits are higher than the risks. The effect of INVEGA at birth in humans is unknown.
The use of antipsychotic medication in the last trimester of pregnancy has been associated with recurrent extrapyramidal symptoms in the newborn.
INVEGA should not be used during pregnancy unless absolutely necessary.
In human studies with paliperidone and human studies with risperidone, paliperidone was excreted in breast milk. Therefore, women who use INVEGA should not breastfeed.
Reproduction ability / Fertility
4.7. Effects on vehicle and machine use
8.4. Undesirable effects
INVEGA's reliability in the treatment of schizophrenia was evaluated in 1205 adult patients participating in 3 double-blind, placebo-controlled 6-week studies. 850 of these patients received a single daily dose of INVEGA at fixed doses of 3-12 mg.
INVEGA's reliability was assessed in 622 patients with schizoaffective disorder participating in two 6-week, double-blind, placebo-controlled studies. In one of these studies, 206 patients were given one of two dose levels of INVEGA: 6 mg (n = 108) with a single dose of 3 mg / day or 12 mg (n = 98) with a reduction to 9 mg. In another study, 214 patients received INVEGA (3-12 mg daily dose) at flexible doses. Both studies included patients who received INVEGA either in the form of monotherapy or in combination with antidepressants and / or mood stabilizers.
The information given in this section was obtained from the total data.
Most adverse drug reactions are mild to moderate.
Infections and infestations:
Common: Urinary tract infection, nasopharyngitis, upper respiratory tract infection Uncommon: Rhinitis
Immune system diseases: Uncommon: Angioedema Rare: Anaphylactic reaction, hypersensitivity
Metabolism and nutritional diseases:
Common: Weight gain, appetite increase
Uncommon: hyperglycaemia, decreased appetite
Uncommon: Anus, Sleep disorders
Nervous system diseases:
Very common: Headache
Common: Dystonia, extrapyramidal disorders, akathisia, tremor, hypertonia, dizziness, increased salivation, sedation, somnolence
Uncommon: syncope, tardive dyskinesia, dysarthria, parkinsonism, dyskinesia, postural dizziness, lethargy
Rare: Transient ischemic attack, Grand mal convulsions, convulsions, Parkinson type walking, Parkinson type muscle stiffness
Unknown: Cerebrovascular event, neuroleptic malignant syndrome
Common: Blurred vision Uncommon: Oculojiric crisis
Common: sinus tachycardia, tachycardia, bundle branch block
Uncommon: first grade atrioventricular block, bradycardia, left bundle branch block, palpitations, abnormal ECG, sinus arrhythmia
Rare: QT extension in ECG
Common: Orthostatic hypotension Uncommon: Hypotension Rare: Ischemia
Respiratory, thoracic disorders and mediastinal disorders:
Common: pharyngolaryngeal pain, nasal congestion, cough Unknown: Aspiration pneumonia
Common: Vomiting, upper abdominal pain, stomach upset, nausea, dyspepsia, mouth instability, constipation
Uncommon: Excess salivary secretion, swelling Unknown: Small bowel obstruction, tongue swelling
Skin and subcutaneous tissue diseases:
Rare: Papillary rash
Musculoskeletal disorders, connective tissue and bone diseases:
Common: arthralgia, back pain, pain in extremities, myalgia
Uncommon: Muscle stiffness, muscle spasms, muscle soreness, musculoskeletal pain, jaw clenching
Rare: Neck retention
Kidney and urinary diseases:
Uncommon: Urinary retention Rare: Urinary incontinence
Reproductive system and breast diseases:
Uncommon: Erectile dysfunction, galactore, amenore, retrograde ejaculation
Rare: Gynecomastia, discharge in the bladder, irregular menstruation, breast tenderness, breast pain, breast engorgement (breast swelling in breast feeding cycle)
Common: Asthenia, fatigue
Uncommon: edema, peripheral edema
Combined Therapy Against Monotherapy
The design of two placebo-controlled, 6-week, double-blind studies in patients with schizoaffective disorder includes the option to use antidepressants (except monoamine oxidase inhibitor) and / or mood stabilizers (lithium, valproate or lamotrigine) for patients. In a patient population assessed for reliability, 230 (55%) patients received INVEGA as monotherapy, and 190 (45%) patients received INVEGA in combination with antidepressants and / or mood stabilizers. Comparing these two subpopulations, patients who received INVEGA in the form of monotherapy only had a higher frequency of nausea (> 3% difference).
Dose-Related Adverse Reactions
Dyspnea, dysarthria and nasopharyngitis at placebo-controlled, 6-week high- and low-dose studies in patients with schizoaffective disorder occurred more frequently (ie, at least 3% difference) when compared to patients receiving low doses of patients receiving high doses of INVEGA. Hypertension is more common when INVEGA is compared with patients receiving high doses in patients receiving low doses.
These class-specific events:
Extrapramidal Symptoms (EPS): Data from 6-week, double-blind, placebo-controlled, fixed-dose studies of schizophrenia (see Section 5.1), placebo (11%) and INVEGA 3 and 6 mg 13% and 10%). Dosage correlations were observed at higher doses of INVEGA (25 and 26% for 9 and 12 mg, respectively). EPS contains an aggregate analysis of the following terms: dyskinesia, dystonia, hyperkinesia, Parkinsonism and tremor. Data from two 6-week, double-blind, placebo-controlled studies in patients with schizoaffective disorder (see Section 5.1) showed similar results.
Weight gain: The percentage of patients who met the weight-gain criteria of 7% or more was compared in the total data from 6-week, double-blind, placebo-controlled, fixed-dose schizophrenic studies (see Section 5.1) and compared with placebo )
A similar frequency was observed for INVEGA 3 and 6 mg (7% and 6%, respectively) and a higher frequency (9% and 9%, respectively) for INVEGA 9 and 12 mg.
In patients with schizoaffective disorder, weight gain of 7% or more in patients treated with INVEGA (5%) in a 6-week, placebo-controlled, two-run non-parametric study (see Section 5.1) compared with placebo-treated patients high. In the study of high and low dose groups, weight gain of 7% or more was 3% in the low dose group, 7% in the high dose group and 1% in the placebo group.
Laboratory tests: Serum Prolaktin. Increase in serum prolactin levels was observed in patients with INVEGA in both sexes receiving 6-week, double-blind, placebo-controlled, fixed-dose schizophrenic studies (see Section 5.1). The maximum mean increase in serum prolactin concentrations was generally observed on the 15th day of treatment, but remained above the baseline level at the end of the study.
Clinical Studies: Long-term, placebo-controlled study of adverse drug reactions
INVEGA's reliability has also been explored by a long-run study designed to evaluate the efficacy of INVEGA in adult schizophrenia patients (See Section 5.1). In general, the type, frequency, and severity of adverse drug reactions reported during the initial 14-week open-ended phase of this study are comparable to 6-week, placebo-controlled, fixed-dose trials. Adverse drug reactions reported in the long-term, double-blind phase of the study were similar in type and severity to those observed at the initial 14-week open-ended phase; but usually occur less frequently.
Venous thromboembolic events have been reported with antipsychotic medications, including cases of pulmonary embolism and deep venous thrombosis-The incidence is unknown.
Reliability information reported with risperidone
Paliperidone is the active metabolite of risperidone. The release profile and pharmacokinetic characteristics of INVEGA are quite different from those seen with oral rapid-release risperidone formulations (see Section 5.2). Clinical trials with risperidone and the reliability information reported in post-marketing experience can be obtained from Risperidone's product information.
Additional information on special populations:
4.9. Overdose and treatment
Generally, the expected signs and symptoms are an increase in the known pharmacological effects of the drug. These include dizziness and sedation, hypotension with tachycardia, QT-prolongation, and extrapyramidal symptoms. Torsade de pointes and ventricular fibrillation have been reported in a patient with overdose. In cases of acute overdosage, multiple drug possibilities should be considered.
The long-term release structure of the product should be considered when assessing treatment needs and recovery. Paliperidone does not have a specific antidote. General supportive measures should be implemented. The airway should be kept open and maintained, adequate oxygenation and ventilation should be provided. Cardiovascular monitoring should be started immediately and continuous electrocardiographic monitoring should be performed for possible arrhythmias. Hypotension and circulatory collapse, intravenous fluids and / or sympathomimetic agent should be treated with appropriate precautions. Gastric lavage (after intubation if the patient is conscious) and the use of activated charcoal with a laxative should be considered. Anticholinergic agents should be administered in cases of severe extrapyramidal symptoms. Strict supervision and observation should continue until the patient comes to himself.
- contains a racemic mixture of paliperidone. Mechanism of action:
Paliperidone is a centrally active dopamine D2 antagonist with predominant serotonergic 5-HT2A antagonist activity. Paliperidone is also active as an antagonist at the a1 and a2 adrenergic receptors and H1 histaminergic receptors. Paliperidone does not have affinity for cholinergic muscarinic or p1-adrenergic and p2-adrenergic receptors. (+)
- and (
- the pharmacological activity of the paliperidone enantiomers is qualitatively and quantitatively similar.
The mechanism of action of paliperidone is not known as it is in other medicines with the effect of schizophrenia. However, it has been suggested that the drug's therapeutic activity in schizophrenia is mediated through a combination of dopamine Type 2 (D2) and serotonin Type 2 (5HT2A) receptor antagonism. Antagonism in receptors other than D2 and 5HT2A may explain some of the other effects of paliperidone.
Centrally effective drugs may affect sleep through time of action mechanisms, drug release profiles and / or dosing time. A placebo-controlled trial of INVEGA 9 mg or placebo for 14 days once a day was performed on 36 volunteers to assess the effect of INVEGA on the sleep structure and continuity of the morning dose. The following observations were recorded (average compared to placebo): The delay time to continuous sleep decreased by 41.0 (SE 18.70) minutes, the delay time to the beginning of sleep decreased by 35.2 (SE 14.99) minutes, the number of waking after the onset of sleep decreased by 7.0 (SE 3.88) the total sleep duration increased by 52.8 (SE 24.01) minutes, the sleep period duration increased by 41.7 (SE 18.75) minutes and the sleep efficiency index increased by 11.0% (SE 5.00). In addition, there was no statistically significant effect on REM sleep, in phase 1 sleep (a statistically significant shortening (11.9 (SE 4.44) minutes compared to placebo and 50.7 (SE 17.67) minutes in stage 2 sleep).
The effects on Paliperidone's QT interval were assessed by randomized, double-blind, multicenter, two-phase 1 study in adults with schizophrenia and schizoaffective disorder and three 6-week, fixed-dose triple efficacy studies with placebo and active control in adults with schizophrenia.
Volunteers were randomized to receive fast-release oral paliperidone (titrated from 4 mg to 8 mg) or single dose moxifloxacin (400 mg) once daily for 7 days in the first phase 1 study (n = 141). The mean steady-state peak plasma concentration reached at 8 mg dose once daily (n = 44) with fast-release oral paliperidone was more than twice as high as the exposure observed at the maximum recommended INVEGA dose (Cmax ss = 113 and 45 ng / mL , respectively). An average of 5.5 milliseconds (90% CI: 3.66; 7.25) was observed in the INVEGA treatment group (n = 44) in linearly differentiated QT correction (QTcLD) averaged over the model adjusted to the model.
In the second phase 1 study (n = 109), the maximum recommended INVEGA dose (12 mg once daily) titrated volunteer placebo and a dose (18 mg once daily) over the recommended interval, or an active ingredient of the same pharmacological drug class control (twice daily 400 mg quetiapine). The primary comparison in this 10-day equal-effort study was made between INVEGA 12 mg and quetiapine. The smallest squares in the QTcLD value in each individual were calculated as 5.1 ms lower than the 400 mg quetiapine administration (mean Cmax 1183 ng / mL) twice daily in the 12 mg INVEGA administration (mean Cmax 34 ng / mL) 90 Cl: -9.2; -0.9); this value meets the previously specified equal efficiency criterion (10 ms). The smallest squares in the QTcLD value in each individual were calculated as 2.3 ms lower than the 400 mg quetiapine administration (mean Cmax 1183 ng / mL) twice daily (mean Cmax 53 ng / mL) in the 18 mg INVEGA administration (% 90 CI: -6.8; 2.3).
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