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Invega Sustenna

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Invega Sustenna

Invega Sustenna

CLINICAL PHARMACOLOGY

Mechanism Of Action

Paliperidone palmitate is hydrolyzed to paliperidone. Paliperidone is the major active metabolite of risperidone. The mechanism of action of paliperidone is unknown. However, it has been proposed that the drug's therapeutic activity in schizophrenia is mediated through a combination of central dopamine Type 2 (D2) and serotonin Type 2 (5HT2A) receptor antagonism.

Pharmacodynamics

Paliperidone is a centrally active dopamine Type 2 (D2) receptor antagonist and a serotonin Type 2 (5HT2A) receptor antagonist. Paliperidone is also active as an antagonist at α1 and α2 adrenergic receptors and H1 histaminergic receptors, which may explain some of the other effects of the drug. Paliperidone has no affinity for cholinergic muscarinic or β1- and β2-adrenergic receptors. The pharmacological activity of the (+)- and (-)- paliperidone enantiomers is qualitatively and quantitatively similar in vitro.

Pharmacokinetics

Absorption and Distribution

Due to its extremely low water solubility, paliperidone palmitate dissolves slowly after intramuscular injection before being hydrolyzed to paliperidone and absorbed into the systemic circulation. Following a single intramuscular dose, the plasma concentrations of paliperidone gradually rise to reach maximum plasma concentrations at a median Tmax of 13 days. The release of the drug starts as early as day 1 and lasts for as long as 126 days.

Following intramuscular injection of single doses (39 mg - 234 mg) in the deltoid muscle, on average, a 28% higher Cmax was observed compared with injection in the gluteal muscle. The two initial deltoid intramuscular injections of 234 mg on day 1 and 156 mg on day 8 help attain therapeutic concentrations rapidly. The release profile and dosing regimen of INVEGA® SUSTENNA® results in sustained therapeutic concentrations. The AUC of paliperidone following INVEGA® SUSTENNA® administration was dose-proportional over a 39 mg-234 mg dose range, and less than dose-proportional for Cmax for doses exceeding 78 mg. The mean steady-state peak:trough ratio for an INVEGA® SUSTENNA® dose of 156 mg was 1.8 following gluteal administration and 2.2 following deltoid administration.

Following administration of paliperidone palmitate the (+) and (-) enantiomers of paliperidone interconvert, reaching an AUC (+) to (-) ratio of approximately 1.6–1.8.

Based on a population analysis, the apparent volume of distribution of paliperidone is 391 L. The plasma protein binding of racemic paliperidone is 74%.

Metabolism and Elimination

In a study with oral immediate-release 14C-paliperidone, one week following administration of a single oral dose of 1 mg immediate-release 14C-paliperidone, 59% of the dose was excreted unchanged into urine, indicating that paliperidone is not extensively metabolized in the liver. Approximately 80% of the administered radioactivity was recovered in urine and 11% in the feces. Four metabolic pathways have been identified in vivo, none of which accounted for more than 10% of the dose: dealkylation, hydroxylation, dehydrogenation, and benzisoxazole scission. Although in vitro studies suggested a role for CYP2D6 and CYP3A4 in the metabolism of paliperidone, there is no evidence in vivo that these isozymes play a significant role in the metabolism of paliperidone. Population pharmacokinetics analyses indicated no discernible difference on the apparent clearance of paliperidone after administration of oral paliperidone between extensive metabolizers and poor metabolizers of CYP2D6 substrates. In vitro studies in human liver microsomes showed that paliperidone does not substantially inhibit the metabolism of medicines metabolized by cytochrome P450 isozymes, including CYP1A2, CYP2A6, CYP2C8/9/10, CYP2D6, CYP2E1, CYP3A4, and CYP3A5.

In vitro studies have shown that paliperidone is a P-gp substrate and a weak inhibitor of P-gp at high concentrations. No in vivo data are available and the clinical relevance is unknown.

The median apparent half-life of paliperidone following INVEGA® SUSTENNA® single-dose administration over the dose range of 39 mg - 234 mg ranged from 25 days - 49 days.

Long-Acting Paliperidone Palmitate Injection versus Oral Extended-Release Paliperidone

INVEGA® SUSTENNA® is designed to deliver paliperidone over a monthly period while extended-release oral paliperidone is administered on a daily basis. The initiation regimen for INVEGA® SUSTENNA® (234 mg/156 mg in the deltoid muscle on Day 1/Day 8) was designed to rapidly attain steady-state paliperidone concentrations when initiating therapy without the use of oral supplementation.

In general, overall initiation plasma levels with INVEGA® SUSTENNA® were within the exposure range observed with 6-12 mg extended-release oral paliperidone. The use of the INVEGA® SUSTENNA® initiation regimen allowed patients to stay in this exposure window of 6-12 mg extended-release oral paliperidone even on trough pre-dose days (Day 8 and Day 36). The intersubject variability for paliperidone pharmacokinetics following delivery from INVEGA® SUSTENNA® was lower relative to the variability determined from extended-release oral paliperidone tablets. Because of the difference in median pharmacokinetic profiles between the two products, caution should be exercised when making a direct comparison of their pharmacokinetic properties.

Drug Interaction Studies

Potential for INVEGA® SUSTENNA® to Affect Other Drugs

In vitro studies in human liver microsomes demonstrated that paliperidone does not substantially inhibit the metabolism of drugs metabolized by cytochrome P450 isozymes, including CYP1A2, CYP2A6, CYP2C8/9/10, CYP2D6, CYP2E1, CYP3A4, and CYP3A5. Therefore, paliperidone is not expected to inhibit clearance of drugs that are metabolized by these metabolic pathways in a clinically relevant manner.

Paliperidone is also not expected to have enzyme inducing properties. Paliperidone is a weak inhibitor of P-glycoprotein (P-gp) at high concentrations. No in vivo data are available, and the clinical relevance is unknown.

In a drug interaction study, co-administration of oral paliperidone extended-release tablets (12 mg once daily for 5 days) with divalproex sodium extended-release tablets (500 mg to 2000 mg once daily) did not affect the steady-state pharmacokinetics (AUC24h and Cmax,ss) of valproate in 13 patients stabilized on valproate. In a clinical study, subjects on stable doses of valproate had comparable valproate average plasma concentrations when oral paliperidone extended-release tablets 3-15 mg/day was added to their existing valproate treatment [see DRUG INTERACTIONS].

Potential for Other Drugs to Affect INVEGA® SUSTENNA®

While in vitro studies indicate that CYP2D6 and CYP3A4 may be minimally involved in paliperidone metabolism, in vivo studies did not demonstrate decreased elimination by these isozymes; they contribute to only a small fraction of total body clearance. In vitro studies demonstrated that paliperidone is a P-gp substrate [see DRUG INTERACTIONS].

Co-administration of oral paliperidone extended-release 6 mg once daily with carbamazepine, a strong inducer of both CYP3A4 and P-gp, at 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. A minor decrease in the amount of drug excreted unchanged in the urine suggests that there was little effect on the CYP metabolism or bioavailability of paliperidone during carbamazepine co-administration [see DRUG INTERACTIONS].

Co-administration of a single dose of oral paliperidone extended-release 12 mg tablet with divalproex sodium extended-release tablets (two 500 mg tablets once daily at steady-state) resulted in an increase of approximately 50% in the Cmax and AUC of paliperidone. Although this interaction has not been studied with INVEGA® SUSTENNA® , a clinically significant interaction would not be expected between divalproex sodium and INVEGA® SUSTENNA® intramuscular injection [see DRUG INTERACTIONS].

Paliperidone is metabolized to a limited extent by CYP2D6. In an interaction study in healthy subjects in which a single 3 mg dose of oral paliperidone extended-release was administered concomitantly with 20 mg per day of paroxetine (a potent CYP2D6 inhibitor), paliperidone exposures were on average 16% (90% CI: 4, 30) higher in CYP2D6 extensive metabolizers. Higher doses of paroxetine have not been studied. The clinical relevance is unknown.

Special Populations

Renal Impairment

INVEGA® SUSTENNA® has not been systematically studied in patients with renal impairment. Based on a limited number of observations with INVEGA® SUSTENNA® in subjects with mild renal impairment and pharmacokinetic simulations, the dose of INVEGA® SUSTENNA® should be reduced in patients with mild renal impairment; INVEGA® SUSTENNA® is not recommended in patients with moderate or severe renal impairment. Although INVEGA® SUSTENNA® was not studied in patients with moderate or severe renal impairment, the disposition of a single oral dose paliperidone 3 mg extended-release tablet was studied in subjects with varying degrees of renal function. Elimination of paliperidone decreased with decreasing estimated creatinine clearance. Total clearance of paliperidone was reduced in subjects with impaired renal function by 32% on average in mild (CrCl = 50 mL/min to < 80 mL/min), 64% in moderate (CrCl = 30 mL/min to < 50 mL/min), and 71% in severe (CrCl = 10 mL/min to < 30 mL/min) renal impairment, corresponding to an average increase in exposure (AUCinf) of 1.5 fold, 2.6 fold, and 4.8 fold, respectively, compared to healthy subjects [see DOSAGE AND ADMINISTRATION and Use In Specific Populations].

Hepatic Impairment

INVEGA® SUSTENNA® has not been studied in patients with hepatic impairment. Based on a study with oral paliperidone in subjects with moderate hepatic impairment (Child-Pugh class B), no dose adjustment is required in patients with mild or moderate hepatic impairment. In the study with oral paliperidone in subjects with moderate hepatic impairment (Child-Pugh class B), the plasma concentrations of free paliperidone were similar to those of healthy subjects, although total paliperidone exposure decreased because of a decrease in protein binding. Paliperidone has not been studied in patients with severe hepatic impairment [see Use In Specific Populations].

Elderly

No dosage adjustment is recommended based on age alone. However, dose adjustment may be required because of age-related decreases in creatinine clearance [see Renal Impairment above and DOSAGE AND ADMINISTRATION].

Race

No dosage adjustment is recommended based on race. No differences in pharmacokinetics were observed between Japanese and Caucasians.

Gender

No dosage adjustment is recommended based on gender, although slower absorption was observed in females in a population pharmacokinetic analysis.

Smoking

No dosage adjustment is recommended based on smoking status. Based on in vitro studies utilizing human liver enzymes, paliperidone is not a substrate for CYP1A2; smoking should, therefore, not have an effect on the pharmacokinetics of paliperidone.

Clinical Studies

The efficacy of INVEGA® SUSTENNA® in the acute treatment of schizophrenia was evaluated in four short-term (one 9-week and three 13-week) double-blind, randomized, placebocontrolled, fixed-dose studies of acutely relapsed adult inpatients who met DSM-IV criteria for schizophrenia. The fixed doses of INVEGA® SUSTENNA® in these studies were given on days 1, 8, and 36 in the 9-week study, and additionally on day 64 of the 13-week studies, i.e., at a weekly interval for the initial two doses and then every 4 weeks for maintenance.

Efficacy was evaluated using the Positive and Negative Syndrome Scale (PANSS), a validated multi-item inventory composed of five factors to evaluate positive symptoms, negative symptoms, disorganized thoughts, uncontrolled hostility/excitement, and anxiety/depression.

In PSY-3007, a 13-week study (n=636) comparing three fixed doses of INVEGA® SUSTENNA® (initial deltoid injection of 234 mg followed by 3 gluteal or deltoid doses of either 39 mg/4 weeks, 156 mg/4 weeks or 234 mg/4 weeks) to placebo, all three doses of INVEGA® SUSTENNA® were superior to placebo in improving the PANSS total score.

In PSY-3003, another 13-week study (n=349) comparing three fixed doses of INVEGA® SUSTENNA® (78 mg/4 weeks, 156 mg/4 weeks, and 234 mg/4 weeks) to placebo, only 156 mg/4 weeks of INVEGA® SUSTENNA® was superior to placebo in improving the PANSS total score.

In PSY-3004, a third 13-week study (n=513) comparing three fixed doses of INVEGA® SUSTENNA® (39 mg/4 weeks, 78 mg/4 weeks, and 156 mg/4 weeks) to placebo, all three doses of INVEGA® SUSTENNA® were superior to placebo in improving the PANSS total score.

In SCH-201, the 9-week study (n=197) comparing two fixed doses of INVEGA® SUSTENNA® (78 mg/4 weeks and 156 mg/4 weeks) to placebo, both doses of INVEGA® SUSTENNA® were superior to placebo in improving PANSS total score. A summary of the mean baseline PANSS scores along with the mean changes from baseline in the four short-term acute schizophrenia studies are provided in Table 8.

Table 8: PANSS Total Score-Change From Baseline to Endpoint-Last Observation Carried Forward in the 4 controlled studies with INVEGA® SUSTENNA®

Study Placebo Doses of Invega Sustenna
39 mg 78 mg 156 mg 234 mg
R092670-PSY-3007
  N 160 155 161 160
  Baseline (mean) 86.8 86.9 - 86.2 88.4
  Change from baseline (mean) -2.9 -8.0* -11.6** -13.2**
R092670-PSY-3003
  N 132 93 94 30
  Baseline (mean) 92.4 - 89.9 90.1 92.2
  Change from baseline (mean) -4.1 -7.9 -11.0* -5.5
R092670-PSY-3004
  N 125 129 128 131
  Baseline (mean) 90.7 90.7 91.2 90.8 -
  Change from baseline (mean) -7.0 -13.6* -13.2* -16.1**
R092670-SCH-201
  N 66 63 68
  Baseline (mean)   87.8 - 88.0 85.2 -
  Change from baseline (mean) 6.2 -5.2** -7.8**
**p-value ≤ 0.001
*p-value < 0.05

The efficacy of INVEGA® SUSTENNA® in maintaining symptomatic control in schizophrenia was established in a longer-term double-blind, placebo-controlled, flexible-dose study involving adult subjects who met DSM-IV criteria for schizophrenia. This study included a minimum 12-week fixed-dose stabilization phase, and a randomized, placebo-controlled phase to observe for relapse. During the double-blind phase, patients were randomized to either the same dose of INVEGA® SUSTENNA® they received during the stabilization phase, i.e., 39 mg, 78 mg, or 156 mg administered every 4 weeks, or to placebo. A total of 410 stabilized patients were randomized to either INVEGA® SUSTENNA® or to placebo until they experienced a relapse of schizophrenia symptoms. Relapse was pre-defined as time to first emergence of one or more of the following: psychiatric hospitalization, ≥ 25% increase (if the baseline score was > 40) or a 10-point increase (if the baseline score was ≤ 40) in total PANSS score on two consecutive assessments, deliberate self-injury, violent behavior, suicidal/homicidal ideation, or a score of ≥ 5 (if the maximum baseline score was ≤ 3) or ≥ 6 (if the maximum baseline score was 4) on two consecutive assessments of the individual PANSS items P1 (Delusions), P2 (Conceptual disorganization), P3 (Hallucinatory behavior), P6 (Suspiciousness/persecution), P7 (Hostility), or G8 (Uncooperativeness). The primary efficacy variable was time to relapse. A pre-planned interim analysis showed a statistically significantly longer time to relapse in patients treated with INVEGA® SUSTENNA® compared to placebo, and the study was stopped early because maintenance of efficacy was demonstrated. Thirty-four percent (34%) of subjects in the placebo group and 10% of subjects in the INVEGA® SUSTENNA® group experienced a relapse event. Reference ID: 3495576 41 There was a significant difference (p-value < 0.0001) between the treatment groups in favor of INVEGA® SUSTENNA® . A Kaplan-Meier plot of time to relapse by treatment group is shown in Figure 1. The time to relapse for subjects in the placebo group was significantly shorter than for the INVEGA® SUSTENNA® group. An examination of population subgroups did not reveal any clinically significant differences in responsiveness on the basis of gender, age, or race.

Figure 1: Kaplan-Meier Plot of Time to Relapse – Interim Analysis

Kaplan-Meier Plot of Time to Relapse - Illustration

Last reviewed on RxList: 5/19/2014
This monograph has been modified to include the generic and brand name in many instances.

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