Paliperidone

IMPORTANT WARNING:

Studies have shown that older adults with dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and may cause changes in mood and personality) who take antipsychotics (medications for mental illness) such as paliperidone have an increased risk of death during treatment. Older adults with dementia may also have a greater chance of having a stroke or ministroke during treatment.

Paliperidone is not approved by the Food and Drug Administration (FDA) for the treatment of behavior problems in older adults with dementia. Talk to the doctor who prescribed this medication, if you, a family member, or someone you care for has dementia and is taking paliperidone. For more information, visit the FDA website: http://www.fda.gov/Drugs

Why is this medication prescribed?

Paliperidone is used to treat the symptoms of schizophrenia (a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). Paliperidone is in a class of medications called atypical antipsychotics. It works by changing the activity of certain natural substances in the brain.

How should this medicine be used?

Paliperidone comes as an extended-release (long-acting) tablet to take by mouth. It is usually taken once a day in the morning with or without food. Take paliperidone at around the same time every day. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take paliperidone exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Swallow the tablets whole with plenty of water or other liquid. Do not split, chew, or crush the tablets. Tell your doctor if you cannot swallow tablets. Your doctor will probably prescribe another medication to treat your condition.

Talk to your doctor about how you are feeling during your treatment. If your symptoms are still bothersome, your doctor may gradually increase your dose, not more often than once every 5 days.

Paliperidone controls the symptoms of schizophrenia but does not cure the condition. Continue to take paliperidone even if you feel well. Do not stop taking paliperidone without talking to your doctor.

Other uses for this medicine

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This medication may be prescribed for other uses; ask your doctor or pharmacist for more information.

What special precautions should I follow?

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Before taking paliperidone,

• tell your doctor and pharmacist if you are allergic to paliperidone, risperidone (Risperdal), or any other medications.
• tell your doctor and pharmacist what prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking or plan to take. Be sure to mention any of the following: antidepressants; certain antibiotics such as erythromycin (E.E.S., E-Mycin, Erythrocin), gatifloxacin (Tequin) (not available in the United States), moxifloxacin (Avelox), and sparfloxacin (Zagam); certain antipsychotics such as chlopromazine (Sonazine, Thorazine), pimozide (Orap), risperidone (Risperdal) and thioridazine; cisapride (Propulsid); levodopa (in Sinemet, in Stalevo); medications for anxiety, high blood pressure, or seizures; medications for irregular heartbeat such as amiodarone (Cordarone), disopyramide (Norpace), dofetilide (Tikosyn); procainamide (Procanbid, Pronestyl), quinidine (Quinidex), and sotalol (Betapace, Betapace AF); sedatives; sleeping pills; and tranquilizers. Your doctor may need to change the doses of your medications or monitor you carefully for side effects.
• tell your doctor if you have or have ever had a prolonged QT interval (a rare heart problem that may cause fainting or irregular heartbeat); slow or irregular heartbeat; a heart attack; low levels of potassium or magnesium in your blood; seizures; a stroke; a head injury; a brain tumor; Parkinson's disease (a disorder of the nervous system that causes difficulties with movement, muscle control, and balance); diabetes; breast cancer; surgery involving the intestines; any condition that causes blockage or narrowing of the esophagus (tube that connects the mouth and stomach), stomach, or intestines such as cystic fibrosis (an inborn disease that causes problems with breathing, digestion, and reproduction), and inflammatory bowel disease (IBD; a group of conditions that cause swelling of the lining of the intestines); and kidney, heart, or liver disease. Also tell your doctor if you drink or have ever drunk large amounts of alcohol and if you use or have ever used street drugs or have overused prescription medications. Tell your doctor if you have ever had to stop taking a medication for mental illness because of severe side effects.
• tell your doctor if you are pregnant, especially if you are in the last few months of your pregnancy, or if you plan to become pregnant or are breast-feeding. If you become pregnant while taking paliperidone, call your doctor. Paliperidone may cause problems in newborns following delivery if it is taken during the last months of pregnancy.
• if you are having surgery, including dental surgery, tell the doctor or dentist that you are taking paliperidone.
• you should know that paliperidone may make you drowsy and may cause difficulty with thinking and movement. Do not drive a car or operate machinery until you know how this medication affects you.
• you should know that alcohol may add to the drowsiness caused by paliperidone. Do not drink alcoholic beverages while you are taking this medication.
• you should know that you may experience hyperglycemia (increases in your blood sugar) while you are taking this medication, even if you do not already have diabetes. If you have schizophrenia, you may be more likely to develop diabetes than people who do not have schizophrenia, and taking paliperidone or similar medications may increase this risk. Tell your doctor immediately if you have any of the following symptoms while you are taking paliperidone: extreme thirst, frequent urination, extreme hunger, blurred vision, or weakness. It is very important to call your doctor as soon as you have any of these symptoms, because high blood sugar can cause more serious symptoms, such as dry mouth, nausea and vomiting, shortness of breath, breath that smells fruity, or decreased consciousness, and may become life-threatening if it is not treated at an early stage.
• you should know that paliperidone may make it harder for your body to cool down when it gets very hot. Tell your doctor if you plan to exercise or be exposed to extreme heat.
• you should know that paliperidone may cause dizziness, lightheadedness, and fainting when you get up too quickly from a lying position. This is more common when you first start taking paliperidone or when your dose is increased. To avoid this problem, get out of bed slowly, resting your feet on the floor for a few minutes before standing up.

What special dietary instructions should I follow?

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Unless your doctor tells you otherwise, continue your normal diet.

What should I do if I forget a dose?

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Take the missed dose as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dosing schedule. Do not take a double dose to make up for a missed one.

What side effects can this medication cause?

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Paliperidone may cause side effects. Tell your doctor if any of these symptoms are severe or do not go away:

• dizziness
• extreme tiredness
• weakness
• headache
• dry mouth
• increased saliva
• weight gain
• stomach pain

Some side effects can be serious. If you experience any of these symptoms or those listed in the IMPORTANT WARNING section, call your doctor immediately:

• fever
• muscle pain or stiffness
• confusion
• fast, pounding, or irregular heartbeat
• sweating
• unusual movements of your face or body that you cannot control
• slow or stiff movements
• restlessness
• painful erection of the penis that lasts for hours

Paliperidone may cause other side effects. Call your doctor if you have any unusual problems while taking this medication.

What should I know about storage and disposal of this medication?

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Keep this medication in the container it came in, tightly closed, and out of reach of children. Store it at room temperature and away from excess heat and moisture (not in the bathroom). Throw away any medication that is outdated or no longer needed. Talk to your pharmacist about the proper disposal of your medication.

In case of emergency/overdose

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In case of overdose, call your local poison control center at 1-800-222-1222. If the victim has collapsed or is not breathing, call local emergency services at 911.

Symptoms of overdose may include:

• unusual movements of your face or body that you cannot control
• slow or stiff movements
• restlessness
• unsteadiness
• drowsiness
• fast heartbeat

What other information should I know?

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Keep all appointments with your doctor.

Do not let anyone else take your medication. Ask your pharmacist any questions you have about refilling your prescription.

You may notice something that looks like a tablet in your stool. This is just the empty tablet shell and does not mean that you did not get your complete dose of medication.

It is important for you to keep a written list of all of the prescription and nonprescription (over-the-counter) medicines you are taking, as well as any products such as vitamins, minerals, or other dietary supplements. You should bring this list with you each time you visit a doctor or if you are admitted to a hospital. It is also important information to carry with you in case of emergencies.

Nidotherapy for schizophrenia

Chamberlain I

Nidotherapy (from the Latin ‘nidus’ or ‘nest’) aims at identifying the need for and making changes to a person’s environment and surroundings. It works alongside other treatments to make improvements to a person’s well being, housing, money management, personal relationships, work and other factors. The aim of nidotherapy is not to change the person (whereas other psychological therapies often aim to make changes in an individual’s behaviour, emotions and thinking) but to create a better ‘fit’ between the environment and the individual. As a consequence the individual may improve, but this is not a direct result of treatment but because a more harmonious relationship has been created with the environment. Benefits of nidotherapy may include improvements in people’s relationships, self-esteem, taking their medication, mental health and generally creating a better life situation. If environmental factors or someone’s surroundings are at all responsible for causing illness and relapse, then nidotherapists and people with schizophrenia can identify these factors together to try and reduce the number and severity of relapses.

This review includes one small pilot study with 52 participants. The study compared nidotherapy with standard care versus standard care alone and lasted 18 months. Findings suggest some limited evidence that those who received nidotherapy might experience a slight improvement in social functioning or personal relationships, mental state and may spend less time as inpatients in hospital over the course of 12 months, but there is no information concerning the appropriateness of this for the individual. However, these limited findings need to be treated with considerable caution. The degree of any possible improvements that come from taking part in nidotherapy remain unclear due to the single study’s small sample size, incomplete evidence and risk of bias. No evidence is available on the effect of nidotherapy on general functioning, quality of life, taking medication, satisfaction with treatment, employment status or adverse effects. Further research is required to fill this gap in knowledge about the effectiveness, benefits and possible hazards of nidotherapy. Until such a time, people with mental health problems, health professionals, managers and policymakers should consider this new therapy an experimental one.

- Background: 

Nidotherapy is a therapeutic method that principally aims to modify the environment of people with schizophrenia and other serious mental illnesses, whilst working in conjunction with, or alongside other treatments. Rather than focusing on direct treatments or interventions, the aim is to help the individual identify the need for, and work to effect environmental change with the aim of minimising the impact of any form of mental disorder on the individual and society.

Objectives: 

To review the effects of nidotherapy added to standard care, compared with standard care or no treatment for people with schizophrenia or related disorders.

Search strategy: 

We searched the Cochrane Schizophrenia Group Trials Register (December 2011) and supplemented this by contacting relevant study authors, handsearching nidotherapy articles and manually searching reference lists.

Selection criteria: 

All randomised controlled trials (RCTs) that compared nidotherapy with standard care or no treatment.

Data collection and analysis: 

We independently selected and quality assessed potential trials. We reliably extracted data. We calculated risk ratios (RR) and 95% confidence intervals (CI) of homogeneous dichotomous data. Scale data were only extracted from valid scales. For non-skewed continuous endpoint data, we estimated mean difference (MD) between groups. Skewed data have been presented in the Data and analyses as 'other data', with acknowledged means and standard deviations. We assessed risk of bias for the included study and used GRADE to create a 'Summary of findings' table.

Main results: 

We included only one study that compared nidotherapy-enhanced standard care with standard care alone (total 52 participants); this study was classified by its authors as a 'pilot study'. The duration of the included study was 18 months in total. The single study examined the short-term (up to six months) and medium-term (between six and 12 months) effects of nidotherapy-enhanced standard care versus standard care.

Nidotherapy-enhanced standard care was favoured over standard care for social functioning in both the short term (n = 50, 1 RCT, MD -2.10, 95% CI -4.66 to 0.46) and medium term (n = 37, 1 RCT, MD -1.70, 95% CI -4.60 to 1.20, Very low quality); however, these results did not reach statistical significance. Results concerning engagement with non-inpatient services favoured the intervention group in both the short term (n = 50, 1 RCT, MD 2.00, 95% CI 0.13 to 3.87) and medium term (n = 37, 1 RCT, MD 1.70, 95% CI -0.09 to 3.49), with statistical significance evident in the short term, but not in the medium term. Results of people leaving the study early favoured the intervention in the short term (n = 52, 1 RCT, RR 0.86, 95% CI 0.06 to 12.98), with slight favour of the control group at medium term (n = 50, 1 RCT, RR 0.99, 95% CI 0.39 to 2.54); again, these results did not reach statistical significance. Results for the adverse effects/events of death (measured by 12 months) favoured the intervention (n = 52, 1 RCT, RR 0.29, 95% CI 0.01 to 6.74, Very low quality) but with no statistical significance. Skewed results were available for mental state, service use, and economic outcomes, and present a mixed picture of the benefits of nidotherapy.

Authors' conclusions: 

Further research is needed into the possible benefits or harms of this newly-formulated therapy. Until such research is available, patients, clinicians, managers and policymakers should consider it an experimental approach.