To the Editor:
We read with interest the article by Limandri (2019) entitled “Long-Acting Injectable Antipsychotic Medications: Why Aren't They Used as Often as Oral Formulations?”, which appeared in the March 2019 issue of the Journal of Psychosocial Nursing and Mental Health Services.
We appreciate Limandri's views regarding the benefits of long-acting injectables (LAIs); however, errors were noted related to the “Pharmacokinetics” and “Barriers to Use of Long-Acting Injectables” sections of the article, as well as Table 1.
Under Pharmacokinetics (Limandri, 2019, p. 8), the statement regarding dosing of paliperidone palmitate could be misinterpreted and lead clinicians to overdose a patient prescribed Invega Sustenna®. The corrected dosing information, per the Invega Sustenna prescribing information (Janssen Pharmaceuticals Inc., 2019), is as follows:
After establishing tolerability, the recommended initiation of Invega Sustenna is with a dose of 234 mg on treatment day 1 and 156 mg one week later, both administered in the deltoid muscle. Following the second initiation dose, monthly maintenance doses can be administered in either the deltoid or gluteal muscle. The first maintenance dose is administered 5 weeks after the first dose. The recommended maintenance dose for treatment of schizophrenia is 117 mg. Some patients may benefit from lower or higher maintenance doses within the additional available strengths (39 mg, 78 mg, 156 mg, and 234 mg).
In addition, under Barriers to Use of Long-Acting Injectables, “It is recommended to inject [LAIs] using the Z-track method…” (Limandri, 2019, p. 8). The recommendation to inject LAIs using the Z-track method could not be found within the Jann and Penzak (2018) article, which is referenced at the end of the sentence. Although it is recommended to administer oil-based conventional depot LAIs via the Z-track method to reduce drug leakage and tissue irritation, second-generation antipsychotics are aqueous based and are administered via standard methods (Stevens, Dawson, & Zummo, 2016). In particular, water is rapidly absorbed following injections of Invega Sustenna and Invega Trinza®, leaving a nidus that will not leak from the injection site (data on file, Janssen Research & Development LLC). As per injection protocols for Janssen LAI clinical trials, which served as the basis for the approved prescribing information and instructions for use, sites were not given instructions to Z-track the injections.
Regarding Table 1, the 9 mg dose is missing for Invega Sustenna. In addition, clarifications are needed regarding paliperidone palmitate and haloperidol decanoate.
We would like to request that the article be corrected, particularly so the concerning dose information does not continue to be communicated to clinicians, potentially putting patients at risk.
Karen Johnston, PharmD
Associate Director, Medical Information
Scientific Knowledge Lead
Jennifer Kern Sliwa, PharmD, BCPP
Director, Medical Information
Cynthia A. Bossie, PhD
Director, US Medical Affairs
Edward Kim, MD, MBA
Therapeutic Area Leader, Schizophrenia,
US Medical Affairs
Janssen Scientific Affairs, LLC
Titusville, New Jersey
- Jann, M.W. & Penzak, S.R. (2018). Long-acting injectable second-generation antipsychotics: An update and comparison between agents. CNS Drugs, 32, 241–257. doi:10.1007/s40263-018-0508-6 [CrossRef]29569082
- Janssen Pharmaceuticals Inc. (2019). Invega Sustenna®. Retrieved from http://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/INVEGA+SUSTENNA-pi.pdf
- Limandri, B. (2019). Long-acting injectable antipsychotic medications: Why aren't they used as often as oral formulations?Journal of Psychosocial Nursing and Mental Health Services, 57(3), 7–10. doi:10.3928/02793695-20190218-02 [CrossRef]
- Stevens, G.L., Dawson, G. & Zummo, J. (2016). Clinical benefits and impact of early use of long-acting injectable antipsychotics for schizophrenia. Early Intervention in Psychiatry, 10, 365–377. doi:10.1111/eip.12278 [CrossRef]
The authors make a good point that the statement “The first injection of paliperidone palmitate (Invega Sustenna®) is 234 mg for 7 days followed by an injection of 156 mg for the next 21 days...” (Limandri, 2019, p. 8). The error is in the attempt to be concise at the mercy of misunderstanding. The first injection of 234 mg is followed in 7 days by a single injection of 156 mg then 21 days later followed by a monthly maintenance dose, usually 117 mg, based on the individual patient's response. The original printed sentence could be misinterpreted to mean weekly injections of 234 mg for 21 days, which would be a gross over-dosage and place the patient in danger. Thus, an erratum has been published in the November issue of the Journal of Psychosocial Nursing and Mental Health Services and the online version of the article has been corrected.
The benefit of Z-track injection is to prevent seepage of the medication as the needle is withdrawn. As this is primarily an issue with oil-based medications, it is less likely with water-based medications, such as paliperidone, and I agree with the authors that standard methods should be used.
Table 1 has also been corrected to include the 9 mg dose, as well as footnotes regarding the conversions of paliperidone palmitate (Invega Trinza®) and haloperidol decanoate.
I regret any misrepresentation of information.
Barbara J. Limandri, PhD, PMHNP, BC
- Limandri, B. (2019). Long-acting injectable anti-psychotic medications: Why aren't they used as often as oral formulations?Journal of Psychosocial Nursing and Mental Health Services, 57(3), 7–10. doi:10.3928/02793695-20190218-02 [CrossRef]