Paliperidone

How it works

It is the major active metabolite of risperidone and acts mainly as an antagonist at dopamine D2 and serotonin 5-HT2A receptors, with additional alpha-adrenergic and histaminergic activity.

Prescribing in practice

• There is an increased risk of stroke and death when antipsychotics are used in elderly patients with dementia-related psychosis, for which paliperidone is not indicated.
• It can raise prolactin, leading to effects such as menstrual disturbance, galactorrhoea or sexual dysfunction, and can cause extrapyramidal symptoms.
• Because it is largely renally excreted, dose adjustment is required in renal impairment in line with the SPC.

Monitoring

Monitor metabolic parameters, prolactin-related symptoms, extrapyramidal effects and renal function, in keeping with antipsychotic monitoring standards.

Counselling the patient

• Report abnormal movements, restlessness or muscle stiffness to your healthcare team.
• Tell your prescriber about breast changes, milk production or sexual or menstrual changes.
• With the long-acting injection, attending for your scheduled appointments is important to maintain the benefit.

Evidence & guidelines

Paliperidone is licensed for schizophrenia and schizoaffective disorder on the basis of randomised controlled trials, and its use aligns with NICE guidance on psychosis and schizophrenia.