Paliperidone

Among the highest of any SGA. D2 blockade in the tuberoinfundibular pathway. Clinical consequences: galactorrhea, menstrual irregularities, sexual dysfunction, gynecomastia, and with prolonged elevation, potential bone mineral density effects. Often the most impactful ongoing side effect, particularly in younger patients and women. Check prolactin if symptomatic.

More than aripiprazole; less than olanzapine or clozapine. Monitor weight at each visit. Metabolic syndrome screening per standard antipsychotic monitoring.

Monitor fasting glucose and lipid panel. Same monitoring protocol as other SGAs.

Lower than FGAs; higher than quetiapine, clozapine, or aripiprazole at standard doses. Dose-dependent. Akathisia and parkinsonism most commonly reported. Manage per EPS toolkit (propranolol for akathisia, benztropine for parkinsonism, dose reduction, or agent switch).

Alpha-1 antagonism. The Sustenna loading protocol (two injections in the first week) can produce notable orthostasis. Monitor blood pressure after loading doses. More common in elderly and volume-depleted patients.

H1 antagonism and alpha-1 effects contribute. Often more prominent at initiation and may improve with continued treatment.

Use caution with concurrent QTc-prolonging medications. Baseline ECG is reasonable.

Pain, induration, or swelling at the injection site. More common with larger-volume injections (Trinza, Hafyera). Proper technique and site rotation reduce occurrence.

The OROS extended-release tablet passes the intact shell after the medication has been released. Patients should be counseled that this is normal and does not mean the medication was not absorbed.