Risperidone 4 MG Oral Tablet
Generic Name: RISPERIDONE
Brand Name: RISPERIDONE
- Substance Name(s):
- RISPERIDONE
DRUG INTERACTIONS
7 Carbamazepine and other enzyme inducers decrease plasma concentrations of risperidone.
Increase the risperidone tablets dose up to double the patient’s usual dose.
Titrate slowly.
( 7.1 ) Fluoxetine, paroxetine, and other CYP 2D6 enzyme inhibitors increase plasma concentrations of risperidone.
Reduce the initial dose.
Do not exceed a final dose of 8 mg per day of risperidone tablets.
( 7.1 ) 7.1 Pharmacokinetic-related Interactions The dose of risperidone tablets should be adjusted when used in combination with CYP2D6 enzyme inhibitors (e.g., fluoxetine, and paroxetine) and enzyme inducers (e.g., carbamazepine) [see Table 18 and Dosage and Administration (2.5) ].
Dose adjustment is not recommended for risperidone tablets when co-administered with ranitidine, cimetidine, amitriptyline, or erythromycin [see Table 18 ] .
Table 18.
Summary of Effect of Coadministered Drugs on Exposure to Active Moiety (Risperidone + 9-Hydroxy-Risperidone) in Healthy Subjects or Patients with Schizophrenia *Change relative to reference Coadministered Drug Dosing Schedule Effect on Active Moiety (Risperidone + 9- Hydroxy- Risperidone (Ratio*) Risperidone Dose Recommendation Coadministered Drug Risperidone AUC C max Enzyme (CYP2D6) inhibitors Fluoxetine 20 mg/day 2 or 3 mg twice daily 1.4 1.5 Re-evaluate dosing.
Do not exceed 8 mg/day Paroxetine 10 mg/day 4 mg/day 1.3 – Re-evaluate dosing.
Do not exceed 8 mg/day 20 mg/day 4 mg/day 1.6 – 40 mg/day 4 mg/day 1.8 – Enzyme (CYP3A/ PgP inducers) Inducers Carbamazepine 573 ± 168 mg/day 3 mg twice daily 0.51 0.55 Titrate dose upwards.
Do not exceed twice the patient’s usual dose Enzyme (CYP3A) inhibitors Ranitidine 150 mg twice daily 1 mg single dose 1.2 1.4 Dose adjustment not needed Cimetidine 400 mg twice daily 1 mg single dose 1.1 1.3 Dose adjustment not needed Erythromycin 500 mg four times daily 1 mg single dose 1.1 0.94 Dose adjustment not needed Other Drugs Amitriptyline 50 mg twice daily 3 mg twice daily 1.2 1.1 Dose adjustment not Needed Effect of Risperidone on other drugs Lithium Repeated oral doses of risperidone tablets (3 mg twice daily) did not affect the exposure (AUC) or peak plasma concentrations (C max ) of lithium (n=13).
Dose adjustment for lithium is not recommended.
Valproate Repeated oral doses of risperidone tablets (4 mg once daily) did not affect the pre-dose or average plasma concentrations and exposure (AUC) of valproate (1000 mg/day in three divided doses) compared to placebo (n=21).
However, there was a 20% increase in valproate peak plasma concentration (C max ) after concomitant administration of risperidone tablets.
Dose adjustment for valproate is not recommended.
Digoxin Risperidone tablets (0.25 mg twice daily) did not show a clinically relevant effect on the pharmacokinetics of digoxin.
Dose adjustment for digoxin is not recommended.
7.2 Pharmacodynamic-related Interactions Centrally Acting Drugs and Alcohol Given the primary CNS effects of risperidone, caution should be used when risperidone tablets are taken in combination with other centrally acting drugs and alcohol.
Drugs with Hypotensive Effects Because of its potential for inducing hypotension, risperidone tablets may enhance the hypotensive effects of other therapeutic agents with this potential.
Levodopa and Dopamine Agonists Risperidone tablets may antagonize the effects of levodopa and dopamine agonists.
Methylphenidate Concomitant use with methylphenidate, when there is change in dosage of either medication, may increase the risk of extrapyramidal symptoms (EPS).
Monitor for symptoms of EPS with concomitant use of risperidone tablets and methylphenidate [see Adverse Reactions ( 6.2 )].
Clozapine Chronic administration of clozapine with risperidone tablets may decrease the clearance of risperidone.
OVERDOSAGE
10 10.1 Human Experience Premarketing experience included eight reports of acute risperidone tablets overdosage with estimated doses ranging from 20 to 300 mg and no fatalities.
In general, reported signs and symptoms were those resulting from an exaggeration of the drug’s known pharmacological effects, i.e., drowsiness and sedation, tachycardia and hypotension, and extrapyramidal symptoms.
One case, involving an estimated overdose of 240 mg, was associated with hyponatremia, hypokalemia, prolonged QT, and widened QRS.
Another case, involving an estimated overdose of 36 mg, was associated with a seizure.
Postmarketing experience includes reports of acute risperidone tablets overdosage, with estimated doses of up to 360 mg.
In general, the most frequently reported signs and symptoms are those resulting from an exaggeration of the drug’s known pharmacological effects, i.e., drowsiness, sedation, tachycardia, hypotension, and extrapyramidal symptoms.
Other adverse reactions reported since market introduction related to risperidone tablets overdose include prolonged QT interval and convulsions.
Torsade de pointes has been reported in association with combined overdose of risperidone tablets and paroxetine.
10.2 Management of Overdosage For the most up to date information on the management of risperidone tablets overdosage, contact a certified poison control center (1-800-222-1222 or www.poison.org).
Provide supportive care including close medical supervision and monitoring.
Treatment should consist of general measures employed in the management of overdosage with any drug.
Consider the possibility of multiple drug overdosage.
Ensure an adequate airway, oxygenation, and ventilation.
Monitor cardiac rhythm and vital signs.
Use supportive and symptomatic measures.
There is no specific antidote to risperidone tablets.
DESCRIPTION
11 Risperidone tablets, USP contain risperidone USP, an atypical antipsychotic belonging to the chemical class of benzisoxazole derivatives.
The chemical designation is 3-[2-[4-(6-fluoro-1,2- benzisoxazol-3-yl)-1-piperidinyl]ethyl]-6,7,8,9-tetrahydro-2-methyl-4H-pyrido[1,2-a]pyrimidin-4-one.
Its molecular formula is C 23 H 27 FN 4 O 2 and its molecular weight is 410.49.
The structural formula is: Risperidone USP is a white to slightly beige powder.
It is practically insoluble in water, freely soluble in methylene chloride, and soluble in methanol and 0.1 N HCl.
Risperidone tablets, USP are for oral administration and available in 0.25 mg (orange), 0.5 mg (orange), 1 mg (white), 2 mg (yellow), 3 mg (orange), and 4 mg (brown) strengths.
Risperidone tablets contain the following inactive ingredients: colloidal silicon dioxide, hypromellose, lactose monohydrate, magnesium stearate, microcrystalline cellulose, propylene glycol (except 1 mg), sodium lauryl sulphate, sodium starch glycolate and polyethylene glycol (1 mg).
Tablets of 0.25 mg, 0.5 mg, 2 mg, 3 mg, and 4 mg also contain talc and titanium dioxide.
0.25 mg, 0.5 mg, and 3 mg tablets contain FD&C Yellow # 6 aluminum lake, the 2 mg tablets contain yellow iron oxide; the 4 mg tablets contain iron oxide red.
structure
CLINICAL STUDIES
14 14.1 Schizophrenia Adults Short-Term Efficacy The efficacy of risperidone tablets in the treatment of schizophrenia was established in four short-term (4- to 8-week) controlled trials of psychotic inpatients who met DSM-III-R criteria for schizophrenia.
Several instruments were used for assessing psychiatric signs and symptoms in these studies, among them the Brief Psychiatric Rating Scale (BPRS), a multi-item inventory of general psychopathology traditionally used to evaluate the effects of drug treatment in schizophrenia.
The BPRS psychosis cluster (conceptual disorganization, hallucinatory behavior, suspiciousness, and unusual thought content) is considered a particularly useful subset for assessing actively psychotic schizophrenic patients.
A second traditional assessment, the Clinical Global Impression (CGI), reflects the impression of a skilled observer, fully familiar with the manifestations of schizophrenia, about the overall clinical state of the patient.
In addition, the Positive and Negative Syndrome Scale (PANSS) and the Scale for Assessing Negative Symptoms (SANS) were employed.
The results of the trials follow: In a 6-week, placebo-controlled trial (n=160) involving titration of risperidone tablets in doses up to 10 mg/day (twice-daily schedule), risperidone tablets were generally superior to placebo on the BPRS total score, on the BPRS psychosis cluster, and marginally superior to placebo on the SANS.
In an 8-week, placebo-controlled trial (n=513) involving 4 fixed doses of risperidone tablets (2 mg/day, 6 mg/day, 10 mg/day, and 16 mg/day, on a twice-daily schedule), all 4 risperidone tablets groups were generally superior to placebo on the BPRS total score, BPRS psychosis cluster, and CGI severity score; the 3 highest risperidone tablets dose groups were generally superior to placebo on the PANSS negative subscale.
The most consistently positive responses on all measures were seen for the 6 mg dose group, and there was no suggestion of increased benefit from larger doses.
In an 8-week, dose comparison trial (n=1356) involving 5 fixed doses of risperidone tablets (1 mg/day, 4 mg/day, 8 mg/day, 12 mg/day, and 16 mg/day, on a twice-daily schedule), the four highest risperidone tablets dose groups were generally superior to the 1 mg risperidone tablets dose group on BPRS total score, BPRS psychosis cluster, and CGI severity score.
None of the dose groups were superior to the 1 mg group on the PANSS negative subscale.
The most consistently positive responses were seen for the 4 mg dose group.
In a 4-week, placebo-controlled dose comparison trial (n=246) involving 2 fixed doses of risperidone tablets (4 and 8 mg/day on a once-daily schedule), both risperidone tablets dose groups were generally superior to placebo on several PANSS measures, including a response measure (>20% reduction in PANSS total score), PANSS total score, and the BPRS psychosis cluster (derived from PANSS).
The results were generally stronger for the 8 mg than for the 4 mg dose group.
Long-Term Efficacy In a longer-term trial, 365 adult outpatients predominantly meeting DSM-IV criteria for schizophrenia and who had been clinically stable for at least 4 weeks on an antipsychotic medication were randomized to risperidone tablets (2-8 mg/day) or to an active comparator, for 1 to 2 years of observation for relapse.
Patients receiving risperidone tablets experienced a significantly longer time to relapse over this time period compared to those receiving the active comparator.
Pediatrics The efficacy of risperidone tablets in the treatment of schizophrenia in adolescents aged 13–17 years was demonstrated in two short-term (6 and 8 weeks), double-blind controlled trials.
All patients met DSM-IV diagnostic criteria for schizophrenia and were experiencing an acute episode at time of enrollment.
In the first trial (study #1), patients were randomized into one of three treatment groups: Risperidone tablets 1-3 mg/day (n = 55, mean modal dose = 2.6 mg), risperidone tablets 4-6 mg/day (n = 51, mean modal dose = 5.3 mg), or placebo (n = 54).
In the second trial (study #2), patients were randomized to either risperidone tablets 0.15-0.6 mg/day (n = 132, mean modal dose = 0.5 mg) or risperidone tablets 1.5–6 mg/day (n = 125, mean modal dose = 4 mg).
In all cases, study medication was initiated at 0.5 mg/day (with the exception of the 0.15-0.6 mg/day group in study #2, where the initial dose was 0.05 mg/day) and titrated to the target dosage range by approximately Day 7.
Subsequently, dosage was increased to the maximum tolerated dose within the target dose range by Day 14.
The primary efficacy variable in all studies was the mean change from baseline in total PANSS score.
Results of the studies demonstrated efficacy of risperidone tablets in all dose groups from 1-6 mg/day compared to placebo, as measured by significant reduction of total PANSS score.
The efficacy on the primary parameter in the 1-3 mg/day group was comparable to the 4-6 mg/day group in study #1, and similar to the efficacy demonstrated in the 1.5–6 mg/day group in study #2.
In study #2, the efficacy in the 1.5-6 mg/day group was statistically significantly greater than that in the 0.15-0.6 mg/day group.
Doses higher than 3 mg/day did not reveal any trend towards greater efficacy.
14.2 Bipolar Mania – Monotherapy Adults The efficacy of risperidone tablets in the treatment of acute manic or mixed episodes was established in two short-term (3-week) placebo-controlled trials in patients who met the DSM-IV criteria for Bipolar I Disorder with manic or mixed episodes.
These trials included patients with or without psychotic features.
The primary rating instrument used for assessing manic symptoms in these trials was the Young Mania Rating Scale (YMRS), an 11-item clinician-rated scale traditionally used to assess the degree of manic symptomatology (irritability, disruptive/aggressive behavior, sleep, elevated mood, speech, increased activity, sexual interest, language/thought disorder, thought content, appearance, and insight) in a range from 0 (no manic features) to 60 (maximum score).
The primary outcome in these trials was change from baseline in the YMRS total score.
The results of the trials follow: In one 3-week placebo-controlled trial (n=246), limited to patients with manic episodes, which involved a dose range of risperidone tablets 1-6 mg/day, once daily, starting at 3 mg/day (mean modal dose was 4.1 mg/day), risperidone tablets were superior to placebo in the reduction of YMRS total score.
In another 3-week placebo-controlled trial (n=286), which involved a dose range of 1-6 mg/day, once daily, starting at 3 mg/day (mean modal dose was 5.6 mg/day), risperidone tablets were superior to placebo in the reduction of YMRS total score.
Pediatrics The efficacy of risperidone tablets in the treatment of mania in children or adolescents with Bipolar I disorder was demonstrated in a 3-week, randomized, double-blind, placebo-controlled, multicenter trial including patients ranging in ages from 10 to 17 years who were experiencing a manic or mixed episode of bipolar I disorder.
Patients were randomized into one of three treatment groups: Risperidone tablets 0.5-2.5 mg/day (n = 50, mean modal dose = 1.9 mg), risperidone tablets 3-6 mg/day (n = 61, mean modal dose = 4.7 mg), or placebo (n = 58).
In all cases, study medication was initiated at 0.5 mg/day and titrated to the target dosage range by Day 7, with further increases in dosage to the maximum tolerated dose within the targeted dose range by Day 10.
The primary rating instrument used for assessing efficacy in this study was the mean change from baseline in the total YMRS score.
Results of this study demonstrated efficacy of risperidone tablets in both dose groups compared with placebo, as measured by significant reduction of total YMRS score.
The efficacy on the primary parameter in the 3-6 mg/day dose group was comparable to the 0.5-2.5 mg/day dose group.
Doses higher than 2.5 mg/day did not reveal any trend towards greater efficacy.
14.3 Bipolar Mania – Adjunctive Therapy with Lithium or Valproate The efficacy of risperidone tablets with concomitant lithium or valproate in the treatment of acute manic or mixed episodes was established in one controlled trial in adult patients who met the DSM-IV criteria for Bipolar I Disorder.
This trial included patients with or without psychotic features and with or without a rapid-cycling course.
In this 3-week placebo-controlled combination trial, 148 in- or outpatients on lithium or valproate therapy with inadequately controlled manic or mixed symptoms were randomized to receive risperidone tablets, placebo, or an active comparator, in combination with their original therapy.
Risperidone tablets, in a dose range of 1-6 mg/day, once daily, starting at 2 mg/day (mean modal dose of 3.8 mg/day), combined with lithium or valproate (in a therapeutic range of 0.6 mEq/L to 1.4 mEq/L or 50 mcg/mL to 120 mcg/mL, respectively) was superior to lithium or valproate alone in the reduction of YMRS total score.
In a second 3-week placebo-controlled combination trial, 142 in- or outpatients on lithium, valproate, or carbamazepine therapy with inadequately controlled manic or mixed symptoms were randomized to receive risperidone tablets or placebo, in combination with their original therapy.
Risperidone tablets, in a dose range of 1-6 mg/day, once daily, starting at 2 mg/day (mean modal dose of 3.7 mg/day), combined with lithium, valproate, or carbamazepine (in therapeutic ranges of 0.6 mEq/L to 1.4 mEq/L for lithium, 50 mcg/mL to 125 mcg/mL for valproate, or 4-12 mcg/mL for carbamazepine, respectively) was not superior to lithium, valproate, or carbamazepine alone in the reduction of YMRS total score.
A possible explanation for the failure of this trial was induction of risperidone and 9-hydroxyrisperidone clearance by carbamazepine, leading to subtherapeutic levels of risperidone and 9-hydroxyrisperidone.
14.4 Irritability Associated with Autistic Disorder Short-Term Efficacy The efficacy of risperidone tablets in the treatment of irritability associated with autistic disorder was established in two 8-week, placebo-controlled trials in children and adolescents (aged 5 to 16 years) who met the DSM-IV criteria for autistic disorder.
Over 90% of these subjects were under 12 years of age and most weighed over 20 kg (16-104.3 kg).
Efficacy was evaluated using two assessment scales: the Aberrant Behavior Checklist (ABC) and the Clinical Global Impression – Change (CGI-C) scale.
The primary outcome measure in both trials was the change from baseline to endpoint in the Irritability subscale of the ABC (ABC-I).
The ABC-I subscale measured the emotional and behavioral symptoms of autism, including aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods.
The CGI-C rating at endpoint was a co-primary outcome measure in one of the studies.
The results of these trials are as follows: In one of the 8-week, placebo-controlled trials, children and adolescents with autistic disorder (n=101), aged 5 to 16 years, received twice daily doses of placebo or risperidone tablets 0.5-3.5 mg/day on a weight-adjusted basis.
Risperidone tablets, starting at 0.25 mg/day or 0.5 mg/day depending on baseline weight (< 20 kg and ≥ 20 kg, respectively) and titrated to clinical response (mean modal dose of 1.9 mg/day, equivalent to 0.06 mg/kg/day), significantly improved scores on the ABC-I subscale and on the CGI-C scale compared with placebo.
In the other 8-week, placebo-controlled trial in children with autistic disorder (n=55), aged 5 to 12 years, risperidone tablets 0.02 to 0.06 mg/kg/day given once or twice daily, starting at 0.01 mg/kg/day and titrated to clinical response (mean modal dose of 0.05 mg/kg/day, equivalent to 1.4 mg/day), significantly improved scores on the ABC-I subscale compared with placebo.
A third trial was a 6-week, multicenter, randomized, double blind, placebo-controlled, fixed-dose study to evaluate the efficacy and safety of a lower than recommended dose of risperidone in subjects (N=96) 5 to 17 years of age with autistic disorder (defined by DSM-IV criteria) and associated irritability and related behavioral symptoms.
Approximately 77% of patients were younger than 12 years of age (mean age = 9), and 88% were male.
Most patients (73%) weighed less than 45 kg (mean weight = 40 kg).
Approximately 90% of patients were antipsychotic-naïve before entering the study.
There were two weight-based, fixed doses of risperidone (high-dose and low-dose).
The high dose was 1.25 mg per day for patients weighing 20 to < 45 kg, and it was 1.75 mg per day for patients weighing ≥ 45 kg.
The low dose was 0.125 mg per day for patients weighing 20 to < 45 kg, and it was 0.175 mg per day for patients weighing ≥ 45 kg.
The dose was administered once daily in the morning, or in the evening if sedation occurred.
The primary efficacy endpoint was the mean change in the Aberrant Behavior Checklist – Irritability subscale (ABC-I) score from baseline to the end of Week 6.
The study demonstrated the efficacy of high-dose risperidone, as measured by the mean change in ABC-I score.
It did not demonstrate efficacy for low-dose risperidone.
The mean baseline ABC-I scores were 29 in the placebo group (n = 35), 27 in the risperidone low-dose group (n = 30), and 28 in the risperidone high-dose group (n = 31).
The mean changes in ABC-I scores were -3.5, -7.4, and -12.4 in the placebo, low-dose, and high-dose group respectively.
The results in the high-dose group were statistically significant (p< 0.001) but not in the low-dose group (p=0.164).
Long-Term Efficacy Following completion of the first 8-week double-blind study, 63 patients entered an open-label study extension where they were treated with risperidone tablets for 4 or 6 months (depending on whether they received risperidone tablets or placebo in the double-blind study).
During this open-label treatment period, patients were maintained on a mean modal dose of risperidone tablets of 1.8-2.1 mg/day (equivalent to 0.05 – 0.07 mg/kg/day).
Patients who maintained their positive response to risperidone tablets (response was defined as ≥ 25% improvement on the ABC-I subscale and a CGI-C rating of ‘much improved’ or ‘very much improved’) during the 4-6 month open-label treatment phase for about 140 days, on average, were randomized to receive risperidone tablets or placebo during an 8-week, double-blind withdrawal study (n=39 of the 63 patients).
A pre-planned interim analysis of data from patients who completed the withdrawal study (n=32), undertaken by an independent Data Safety Monitoring Board, demonstrated a significantly lower relapse rate in the risperidone tablets group compared with the placebo group.
Based on the interim analysis results, the study was terminated due to demonstration of a statistically significant effect on relapse prevention.
Relapse was defined as ≥ 25% worsening on the most recent assessment of the ABC-I subscale (in relation to baseline of the randomized withdrawal phase).
HOW SUPPLIED
16 /STORAGE AND HANDLING 16.1 How Supplied Risperidone Tablets Risperidone Tablets, USP 0.25 mg are orange, circular, biconvex, film-coated tablets, engraved with ‘RI1’ on one side and plain on other and are supplied as follows: Bottles of 60’s with child-resistant closure NDC 27241-002-06 Bottles of 500’s NDC 27241-002-50 Risperidone Tablets, USP 0.5 mg are orange, circular, biconvex, film-coated tablets, engraved with ‘RI2’ on one side and plain on other and are supplied as follows: Bottles of 60’s with child-resistant closure NDC 27241-003-06 Bottles of 500’s NDC 27241-003-50 Risperidone Tablets, USP 1 mg are white to off white, circular, biconvex, film-coated tablets, engraved with ‘RI3’ on one side and plain on other and are supplied as follows: Bottles of 60’s with child-resistant closure NDC 27241-001-06 Bottles of 500’s NDC 27241-001-50 Risperidone Tablets, USP 2 mg are yellow, circular, biconvex film-coated tablets, engraved with ‘RI4’ on one side and plain on other and are supplied as follows: Bottles of 60’s with child-resistant closure NDC 27241-004-06 Bottles of 500’s NDC 27241-004-50 Risperidone Tablets, USP 3 mg are orange, capsule shaped, biconvex film-coated tablets, engraved with ‘RI5’ on one side and plain on other and are supplied as follows: Bottles of 60’s with child-resistant closure NDC 27241-005-06 Bottles of 500’s NDC 27241-005-50 Risperidone Tablets, USP 4 mg are brown, ovaloid, biconvex, film-coated tablets, engraved with ‘RI6’ on one side and plain on other and are supplied as follows: Bottles of 60’s with child-resistant closure NDC 27241-006-06 Bottles of 500’s NDC 27241-006-50 16.2 Storage and Handling Risperidone tablets should be stored at 20° to 25°C (68° to 77°F); excursions permitted between 15° to 30°C (59° to 86°F) [see USP controlled room temperature].
Protect from light and moisture.
Keep out of reach of children.
RECENT MAJOR CHANGES
Warnings and Precautions ( 5.3 , 5.4 ) 2/2021
GERIATRIC USE
8.5 Geriatric Use Clinical studies of risperidone tablets in the treatment of schizophrenia did not include sufficient numbers of patients aged 65 and over to determine whether or not they respond differently than younger patients.
Other reported clinical experience has not identified differences in responses between elderly and younger patients.
In general, a lower starting dose is recommended for an elderly patient, reflecting a decreased pharmacokinetic clearance in the elderly, as well as a greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy [see Clinical Pharmacology (12.3) and Dosage & Administration (2.4 , 2.5) ] .
While elderly patients exhibit a greater tendency to orthostatic hypotension, its risk in the elderly may be minimized by limiting the initial dose to 0.5 mg twice daily followed by careful titration [see Warnings and Precautions (5.7) ] .
Monitoring of orthostatic vital signs should be considered in patients for whom this is of concern.
This drug is substantially excreted by the kidneys, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function.
Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection, and it may be useful to monitor renal function [see Dosage & Administration (2.4) ] .
DOSAGE FORMS AND STRENGTHS
3 Risperidone tablets, USP are available in the following strengths and colors: 0.25 mg (orange), 0.5 mg (orange), 1 mg (white), 2 mg (yellow), 3 mg (orange), and 4 mg (brown).
0.25 mg, 0.5 mg, 1 mg and 2 mg are circular shaped.
3 mg are capsule shaped and 4 mg in ovaloid shaped.
Risperidone tablets, USP are engraved with “RI1”, “RI2”, “RI3”, “RI4”, “RI5” and “RI6” on one side on “0.25”, “0.5”, “1”, “2”, “3” and “4” respectively and plain on other side.
Tablets: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, and 4 mg ( 3 )
MECHANISM OF ACTION
12.1 Mechanism of Action The mechanism of action of risperidone in schizophrenia is unclear.
The drug’s therapeutic activity in schizophrenia could be mediated through a combination of dopamine Type 2 (D 2 ) and serotonin Type 2 (5HT 2 ) receptor antagonism.
The clinical effect from risperidone results from the combined concentrations of risperidone and its major metabolite, 9-hydroxyrisperidone (paliperidone) [see Clinical Pharmacology ( 12.3 )] .
Antagonism at receptors other than D 2 and 5HT 2 may explain some of the other effects of risperidone [see Clinical Pharmacology ( 12.1 )] .
INDICATIONS AND USAGE
1 Risperidone tablets are an atypical antipsychotic indicated for: Treatment of schizophrenia ( 1.1 ) As monotherapy or adjunctive therapy with lithium or valproate, for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder ( 1.2 ) Treatment of irritability associated with autistic disorder ( 1.3 ) 1.1 Schizophrenia Risperidone tablets are indicated for the treatment of schizophrenia.
Efficacy was established in 4 short-term trials in adults, 2 short-term trials in adolescents (ages 13 to 17 years), and one long-term maintenance trial in adults [see Clinical Studies (14.1) ] .
1.2 Bipolar Mania Monotherapy Risperidone tablets are indicated for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder.
Efficacy was established in 2 short-term trials in adults and one short-term trial in children and adolescents (ages 10 to 17 years) [see Clinical Studies (14.2) ] .
Adjunctive Therapy Risperidone tablets adjunctive therapy with lithium or valproate is indicated for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder.
Efficacy was established in one short-term trial in adults [see Clinical Studies (14.3) ] .
1.3 Irritability Associated with Autistic Disorder Risperidone tablets are indicated for the treatment of irritability associated with autistic disorder, including symptoms of aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods.
Efficacy was established in 3 short-term trials in children and adolescents (ages 5 to 17 years) [see Clinical Studies (14.4) ] .
PEDIATRIC USE
8.4 Pediatric Use Approved Pediatric Indications Schizophrenia The efficacy and safety of risperidone tablets in the treatment of schizophrenia were demonstrated in 417 adolescents, aged 13 to 17 years, in two short-term (6 and 8 weeks, respectively) double-blind controlled trials [see Indications and Usage (1.1) , Adverse Reactions (6.1) , and Clinical Studies (14.1) ] .
Additional safety and efficacy information was also assessed in one long-term (6-month) open-label extension study in 284 of these adolescent patients with schizophrenia.
Safety and effectiveness of risperidone tablets in children less than 13 years of age with schizophrenia have not been established.
Bipolar I Disorder The efficacy and safety of risperidone tablets in the short-term treatment of acute manic or mixed episodes associated with Bipolar I Disorder in 169 children and adolescent patients, aged 10 to 17 years, were demonstrated in one double-blind, placebo-controlled, 3-week trial [see Indications and Usage (1.2) , Adverse Reactions (6.2) , and Clinical Studies (14.2) ] .
Safety and effectiveness of risperidone tablets in children less than 10 years of age with bipolar disorder have not been established.
Autistic Disorder The efficacy and safety of risperidone tablets in the treatment of irritability associated with autistic disorder were established in two 8-week, double-blind, placebo-controlled trials in 156 children and adolescent patients, aged 5 to 16 years [see Indications and Usage (1.3) , Adverse Reactions (6.1) and Clinical Studies (14.4) ] .
Additional safety information was also assessed in a long-term study in patients with autistic disorder, or in short- and long-term studies in more than 1200 pediatric patients with psychiatric disorders other than autistic disorder, schizophrenia, or bipolar mania who were of similar age and weight, and who received similar dosages of risperidone tablets as patients treated for irritability associated with autistic disorder.
A third study was a 6-week, multicenter, randomized, double-blind, placebo-controlled, fixed-dose study to evaluate the efficacy and safety of a lower than recommended dose of risperidone in subjects 5 to 17 years of age with autistic disorder and associated irritability, and related behavioral symptoms.
There were two weight-based, fixed doses of risperidone (high-dose and low-dose).
The high dose was 1.25 mg per day for patients weighing 20 to < 45 kg, and it was 1.75 mg per day for patients weighing ≥ 45 kg.The low dose was 0.125 mg per day for patients weighing 20 to < 45 kg, and it was 0.175 mg per day for patients weighing ≥ 45 kg.
The study demonstrated the efficacy of high-dose risperidone, but it did not demonstrate efficacy for low-dose risperidone.
Adverse Reactions in Pediatric Patients Tardive Dyskinesia In clinical trials in 1885 children and adolescents treated with risperidone tablets, 2 (0.1%) patients were reported to have tardive dyskinesia, which resolved on discontinuation of risperidone tablets treatment [see also Warnings and Precautions (5.4) ] .
Weight Gain Weight gain has been observed in children and adolescents during treatment with risperidone tablets.
Clinical monitoring of weight is recommended during treatment.
Data derive from short-term placebo-controlled trials and longer-term uncontrolled studies in pediatric patients (ages 5 to 17 years) with schizophrenia, bipolar disorder, autistic disorder, or other psychiatric disorders.
In the short-term trials (3 to 8 weeks), the mean weight gain for risperidone tablets-treated patients was 2 kg, compared to 0.6 kg for placebo-treated patients.
In these trials, approximately 33% of the risperidone tablets group had weight gain ≥7%, compared to 7% in the placebo group.
In longer-term, uncontrolled, open-label pediatric studies, the mean weight gain was 5.5 kg at Week 24 and 8 kg at Week 48 [see Warnings and Precautions (5.5) and Adverse Reactions (6.1)] .
Somnolence Somnolence was frequently observed in placebo-controlled clinical trials of pediatric patients with autistic disorder.
Most cases were mild or moderate in severity.
These events were most often of early onset with peak incidence occurring during the first two weeks of treatment, and transient with a median duration of 16 days.
Somnolence was the most commonly observed adverse reaction in the clinical trial of bipolar disorder in children and adolescents, as well as in the schizophrenia trials in adolescents.
As was seen in the autistic disorder trials, these adverse reactions were most often of early onset and transient in duration [see Adverse Reactions (6.1 , 6.2) ] .
Patients experiencing persistent somnolence may benefit from a change in dosing regimen [see Dosage & Administration (2.1 , 2.2 , and 2.3) ] .
Hyperprolactinemia Risperidone tablets have been shown to elevate prolactin levels in children and adolescents as well as in adults [see Warnings and Precautions (5.6) ] .
In double-blind, placebo-controlled studies of up to 8 weeks duration in children and adolescents (aged 5 to 17 years) with autistic disorder or psychiatric disorders other than autistic disorder, schizophrenia, or bipolar mania, 49% of patients who received risperidone tablets had elevated prolactin levels compared to 2% of patients who received placebo.
Similarly, in placebo-controlled trials in children and adolescents (aged 10 to 17 years) with bipolar disorder, or adolescents (aged 13 to 17 years) with schizophrenia, 82–87% of patients who received risperidone tablets had elevated levels of prolactin compared to 3–7% of patients on placebo.
Increases were dose-dependent and generally greater in females than in males across indications.
In clinical trials in 1885 children and adolescents, galactorrhea was reported in 0.8% of risperidone tablets-treated patients and gynecomastia was reported in 2.3% of risperidone tablets-treated patients.
Growth and Sexual Maturation The long-term effects of risperidone tablets on growth and sexual maturation have not been fully evaluated in children and adolescents.
Juvenile Animal Studies Juvenile dogs were treated with oral risperidone from weeks 10 to 50 of age (equivalent to the period of childhood through adolescence in humans), at doses of 0.31, 1.25, or 5 mg/kg/day, which are 1.2, 3.4, and 13.5 times the MRHD of 6 mg/day for children, based on mg/m 2 body surface area.
Bone length and density were decreased with a no-effect dose of 0.31 mg/kg/day; this dose produced plasma AUC of risperidone plus its active metabolite paliperidone (9-hydroxy-risperidone) that were similar to those in children and adolescents receiving the MRHD of 6 mg/day.
In addition, sexual maturation was delayed at all doses in both males and females.
The above effects showed little or no reversibility in females after a 12 week drug-free recovery period.
Juvenile rats, treated with oral risperidone from days 12 to 50 of age (equivalent to the period of infancy through adolescence in humans) showed impaired learning and memory performance (reversible only in females), with a no-effect dose of 0.63 mg/kg/day which is 0.5 times the MRHD of 6 mg/day for children, based on mg/m 2 body surface area.
This dose produced plasma AUC of risperidone plus paliperidone about half the exposure observed in humans at the MRHD.
No other consistent effects on neurobehavioral or reproductive development were seen up to the highest tested dose of 1.25 mg/kg/day which is 1 time the MRHD and produced plasma AUC of risperidone plus paliperidone that were about two thirds of those observed in humans at the MRHD of 6 mg/day for children.
PREGNANCY
8.1 Pregnancy Pregnancy Exposure Registry There is a pregnancy exposure registry that monitors pregnancy outcomes in women exposed to atypical antipsychotics, including risperidone, during pregnancy.
Healthcare providers are encouraged to register patients by contacting the National Pregnancy Registry for Atypical Antipsychotics at 1-866-961-2388 or online at http://womensmentalhealth.org/clinical-and-research-programs/pregnancyregistry/ .
Risk Summary Neonates exposed to antipsychotic drugs during the third trimester of pregnancy are at risk for extrapyramidal and/or withdrawal symptoms following delivery (see Clinical Considerations) .
Overall, available data from published epidemiologic studies of pregnant women exposed to risperidone have not established a drug-associated risk of major birth defects, miscarriage, or adverse maternal or fetal outcomes (see Data).
There are risks to the mother associated with untreated schizophrenia or bipolar I disorder and with exposure to antipsychotics, including risperidone, during pregnancy (see Clinical Considerations) .
Oral administration of risperidone to pregnant mice caused cleft palate at doses 3 to 4 times the maximum recommended human dose (MRHD) with maternal toxicity observed at 4-times MRHD based on mg/m 2 body surface area.
Risperidone was not teratogenic in rats or rabbits at doses up to 6-times the MRHD based on mg/m 2 body surface area.
Increased stillbirths and decreased birth weight occurred after oral risperidone administration to pregnant rats at 1.5-times the MRHD based on mg/m 2 body surface area.
Learning was impaired in offspring of rats when the dams were dosed at 0.6-times the MRHD and offspring mortality increased at doses 0.1 to 3 times the MRHD based on mg/m 2 body surface area.
The estimated background risk of major birth defects and miscarriage for the indicated population is unknown.
All pregnancies have a background risk of birth defect, loss, or other adverse outcomes.
In the U.S.
general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20%, respectively.
Clinical Considerations Disease-associated maternal and/or embryo/fetal risk There is a risk to the mother from untreated schizophrenia or bipolar I disorder, including increased risk of relapse, hospitalization, and suicide.
Schizophrenia and bipolar I disorder are associated with increased adverse perinatal outcomes, including preterm birth.
It is not known if this is a direct result of the illness or other comorbid factors.
Fetal/Neonatal Adverse Reactions Extrapyramidal and/or withdrawal symptoms, including agitation, hypertonia, hypotonia, tremor, somnolence, respiratory distress, and feeding disorder have been reported in neonates who were exposed to antipsychotic drugs, including risperidone, during the third trimester of pregnancy.
These symptoms have varied in severity.
Monitor neonates for extrapyramidal and/or withdrawal symptoms and manage symptoms appropriately.
Some neonates recovered within hours or days without specific treatment; others required prolonged hospitalization.
Data Human Data Published data from observational studies, birth registries, and case reports on the use of atypical antipsychotics during pregnancy do not report a clear association with antipsychotics and major birth defects.
A prospective observational study including 6 women treated with risperidone demonstrated placental passage of risperidone.
A retrospective cohort study from a Medicaid database of 9258 women exposed to antipsychotics during pregnancy did not indicate an overall increased risk for major birth defects.
There was a small increase in the risk of major birth defects (RR=1.26, 95% CI 1.02-1.56) and of cardiac malformations (RR=1.26, 95% CI 0.88-1.81) in a subgroup of 1566 women exposed to risperidone during the first trimester of pregnancy; however, there is no mechanism of action to explain the difference in malformation rates.
Animal Data Oral administration of risperidone to pregnant mice during organogenesis caused cleft palate at 10 mg/kg/day which is 3 times the MRHD of 16 mg/day based on mg/m 2 body surface area: maternal toxicity occurred at 4 times the MRHD.
Risperidone was not teratogenic when administered orally to rats at 0.6 to 10 mg/kg/day and rabbits at 0.3 to 5 mg/kg/day, which are up to 6 times the MRHD of 16 mg/day risperidone based on mg/m 2 body surface area.
Learning was impaired in offspring of rats dosed orally throughout pregnancy at 1 mg/kg/day which is 0.6 times the MRHD and neuronal cell death increased in fetal brains of offspring of rats dosed during pregnancy at 1 and 2 mg/kg/day which are 0.6 and 1.2 times the MRHD based on mg/m 2 body surface area; postnatal development and growth of the offspring were also delayed.
Rat offspring mortality increased during the first 4 days of lactation when pregnant rats were dosed throughout gestation at 0.16 to 5 mg/kg/day which are 0.1 to 3 times the MRHD of 16 mg/day based on mg/m 2 body surface area.
It is not known whether these deaths were due to a direct effect on the fetuses or pups or to effects on the dams; a no-effect dose could not be determined.
The rate of stillbirths was increased at 2.5 mg/kg or 1.5 times the MRHD based on mg/m 2 body surface area.
In a rat cross-fostering study the number of live offspring was decreased, the number of stillbirths increased, and the birth weight was decreased in offspring of drug-treated pregnant rats.
In addition, the number of deaths increased by Day 1 among offspring of drug-treated pregnant rats, regardless of whether or not the offspring were cross-fostered.
Risperidone also appeared to impair maternal behavior in that offspring body weight gain and survival (from Day 1 to 4 of lactation) were reduced in offspring born to control but reared by drug-treated dams.
All of these effects occurred at 5 mg/kg which is 3 times the MRHD based on mg/m 2 and the only dose tested in the study.
NUSRING MOTHERS
8.3 Females and Males of Reproductive Potential Infertility Females Based on the pharmacologic action of risperidone (D 2 receptor antagonism), treatment with risperidone may result in an increase in serum prolactin levels , which may lead to a reversible reduction in fertility in females of reproductive potential [see Warnings and Precautions ( 5.6 )].
BOXED WARNING
WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.
Risperidone tablets are not approved for the treatment of patients with dementia-related psychosis.
[see Warnings and Precautions (5.1) ] WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS See full prescribing information for complete boxed warning Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.
Risperidone tablets are not approved for use in patients with dementia-related psychosis.
( 5.1 )
WARNING AND CAUTIONS
5 WARNINGS AND PRECAUTIONS Cerebrovascular events, including stroke, in elderly patients with dementia-related psychosis: Risperidone tablets are not approved for use in patients with dementia-related psychosis ( 5.2 ) Neuroleptic Malignant Syndrome: Manage with immediate discontinuation of risperidone tablets and close monitoring.
( 5.3 ) Tardive dyskinesia: Consider discontinuing risperidone tablets if clinically indicated.
( 5.4 ) Metabolic Changes: Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular / cerebrovascular risk.
These metabolic changes include hyperglycemia, dyslipidemia, and weight gain.
( 5.5 ) Hyperglycemia and Diabetes Mellitus: Monitor patients for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia and weakness.
Monitor glucose regularly in patients with diabetes or at risk for diabetes.
( 5.5 ) Dyslipidemia: Undesirable alterations have been observed in patients treated with atypical antipsychotics.
( 5.5 ) Weight Gain : Significant weight gain has been reported.
Monitor weight gain.
( 5.5 ) Hyperprolactinemia: Prolactin elevations occur and persist during chronic administration.
( 5.6 ) Orthostatic hypotension: For patients at risk, consider a lower starting dose and slower titration.
( 5.7 ) Leukopenia, Neutropenia, and Agranulocytosis: Perform complete blood counts in patients with a history of clinically significant low white blood cell count (WBC).
Consider discontinuing risperidone tablets if a clinically significant decline in WBC occurs in the absence of other causative factors.
( 5.9 ) Potential for cognitive and motor impairment: Use caution when operating machinery.
( 5.10 ) Seizures: Use cautiously in patients with a history of seizures or with conditions that lower the seizure threshold.
( 5.11 ) 5.1 Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death.
Analyses of 17 placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients.
Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group.
Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature.
Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality.
The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear.
In two of four placebo-controlled trials in elderly patients with dementia-related psychosis, a higher incidence of mortality was observed in patients treated with furosemide plus risperidone tablets when compared to patients treated with risperidone tablets alone or with placebo plus furosemide.
No pathological mechanism has been identified to explain this finding, and no consistent pattern for cause of death was observed.
Risperidone tablets are not approved for the treatment of dementia-related psychosis [see Boxed Warning ] .
5.2 Cerebrovascular Adverse Reactions, Including Stroke, in Elderly Patients with Dementia-Related Psychosis Cerebrovascular adverse reactions (e.g., stroke, transient ischemic attack), including fatalities, were reported in patients (mean age 85 years; range 73-97) in trials of risperidone in elderly patients with dementia-related psychosis.
In placebo-controlled trials, there was a significantly higher incidence of cerebrovascular adverse events in patients treated with risperidone compared to patients treated with placebo.
Risperidone tablets are not approved for the treatment of patients with dementia-related psychosis.
[see Boxed Warning and Warnings and Precautions (5.1) ] .
5.3 Neuroleptic Malignant Syndrome Neuroleptic Malignant Syndrome (NMS), a potentially fatal symptom complex, has been reported in association with antipsychotic drugs.
Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status including delirium, and autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia).
Additional signs may include elevated creatine phosphokinase, myoglobinuria (rhabdomyolysis), and acute renal failure.
If NMS is suspected , immediately discontinue risperidone tablets and provide symptomatic treatment and monitoring.
5.4 Tardive Dyskinesia Tardive dyskinesia, a syndrome consisting of potentially irreversible, involuntary, dyskinetic movements, may develop in patients treated with antipsychotic drugs.
Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to predict which patients will develop the syndrome.
Whether antipsychotic drug products differ in their potential to cause tardive dyskinesia is unknown.
The risk of developing tardive dyskinesia and the likelihood that it will become irreversible increase with the duration of treatment and the cumulative dose.
The syndrome can develop after relatively brief treatment periods, even at low doses.
It may also occur after discontinuation of treatment.
Tardive dyskinesia may remit, partially or completely, if antipsychotic treatment is discontinued.
Antipsychotic treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome, possibly masking the underlying process.
The effect that symptomatic suppression has upon the long-term course of the syndrome is unknown.
Given these considerations, risperidone tablets should be prescribed in a manner that is most likely to minimize the occurrence of tardive dyskinesia.
Chronic antipsychotic treatment should generally be reserved for patients: (1) who suffer from a chronic illness that is known to respond to antipsychotic drugs, and (2) for whom alternative, equally effective, but potentially less harmful treatments are not available or appropriate.
In patients who do require chronic treatment, use the lowest dose and the shortest duration of treatment producing a satisfactory clinical response.
Periodically reassess the need for continued treatment.
If signs and symptoms of tardive dyskinesia appear in a patient on risperidone tablets, drug discontinuation should be considered.
However, some patients may require treatment with risperidone tablets despite the presence of the syndrome.
5.5 Metabolic Changes Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular/cerebrovascular risk.
These metabolic changes include hyperglycemia, dyslipidemia, and body weight gain.
While all of the drugs in the class have been shown to produce some metabolic changes, each drug has its own specific risk profile.
Hyperglycemia and Diabetes Mellitus Hyperglycemia and diabetes mellitus, in some cases extreme and associated with ketoacidosis or hyperosmolar coma or death, have been reported in patients treated with atypical antipsychotics including risperidone tablets.
Assessment of the relationship between atypical antipsychotic use and glucose abnormalities is complicated by the possibility of an increased background risk of diabetes mellitus in patients with schizophrenia and the increasing incidence of diabetes mellitus in the general population.
Given these confounders, the relationship between atypical antipsychotic use and hyperglycemia-related adverse events is not completely understood.
However, epidemiological studies suggest an increased risk of treatment-emergent hyperglycemia-related adverse events in patients treated with the atypical antipsychotics.
Precise risk estimates for hyperglycemia-related adverse events in patients treated with atypical antipsychotics are not available.
Patients with an established diagnosis of diabetes mellitus who are started on atypical antipsychotics, including risperidone tablets, should be monitored regularly for worsening of glucose control.
Patients with risk factors for diabetes mellitus (e.g., obesity, family history of diabetes) who are starting treatment with atypical antipsychotics, including risperidone tablets, should undergo fasting blood glucose testing at the beginning of treatment and periodically during treatment.
Any patient treated with atypical antipsychotics, including risperidone tablets, should be monitored for symptoms of hyperglycemia including polydipsia, polyuria, polyphagia, and weakness.
Patients who develop symptoms of hyperglycemia during treatment with atypical antipsychotics, including risperidone tablets, should undergo fasting blood glucose testing.
In some cases, hyperglycemia has resolved when the atypical antipsychotic, including risperidone tablets, was discontinued; however, some patients required continuation of anti-diabetic treatment despite discontinuation of risperidone tablets.
Pooled data from three double-blind, placebo-controlled schizophrenia studies and four double-blind, placebo-controlled bipolar monotherapy studies are presented in Table 2.
Table 2.
Change in Random Glucose from Seven Placebo-Controlled, 3- to 8-Week, Fixed- or Flexible-Dose Studies in Adult Subjects with Schizophrenia or Bipolar Mania Risperidone Tablets Placebo 1–8 mg/day >8–16 mg/day Mean change from baseline (mg/dL) Serum Glucose n=555 – 1.4 n=748 0.8 n=164 0.6 Proportion of patients with shifts Serum Glucose (<140 mg/dL to ≥200 mg/dL) 0.6% (3/525) 0.4% (3/702) 0% (0/158) In longer-term, controlled and uncontrolled studies, risperidone tablets were associated with a mean change in glucose of +2.8 mg/dL at Week 24 (n=151) and +4.1 mg/dL at Week 48 (n=50).
Data from the placebo-controlled 3- to 6-week study in children and adolescents with schizophrenia (13–17 years of age), bipolar mania (10–17 years of age), or autistic disorder (5 to 17 years of age) are presented in Table 3.
Table 3.
Change in Fasting Glucose from Three Placebo-Controlled, 3- to 6-Week, Fixed-Dose Studies in Children and Adolescents with Schizophrenia (13–17 years of age), Bipolar Mania (10–17 years of age), or Autistic Disorder (5 to 17 years of age) Risperidone Tablets Placebo 0.5-6 mg/day Mean change from baseline (mg/dL) Serum Glucose n=76 -1.3 n=135 2.6 Proportion of patients with shifts Serum Glucose (<100 mg/dL to ≥126 mg/dL) 0% (0/64) 0.8% (1/120) In longer-term, uncontrolled, open-label extension pediatric studies, risperidone tablets were associated with a mean change in fasting glucose of +5.2 mg/dL at Week 24 (n=119).
Dyslipidemia Undesirable alterations in lipids have been observed in patients treated with atypical antipsychotics.
Pooled data from 7 placebo-controlled, 3- to 8- week, fixed- or flexible-dose studies in adult subjects with schizophrenia or bipolar mania are presented in Table 4.
Table 4.
Change in Random Lipids from Seven Placebo-Controlled, 3- to 8-Week, Fixed- or Flexible -Dose Studies in Adult Subjects with Schizophrenia or Bipolar Mania Risperidone Tablets Placebo 1–8 mg/day >8–16 mg/day Mean change from baseline (mg/dL) Cholesterol n=559 n=742 n=156 Change from baseline 0.6 6.9 1.8 Triglycerides n=183 n=307 n=123 Change from baseline -17.4 -4.9 -8.3 Proportion of patients with shifts Cholesterol (<200 mg/dL to ≥240 mg/dL) 2.7% (10/368) 4.3% (22/516) 6.3% (6/96) Triglycerides 1.1% 2.7% 2.5% (<500 mg/dL to ≥500 mg/dL) (2/180) (8/301) (3/121) In longer-term, controlled and uncontrolled studies, risperidone tablets were associated with a mean change in (a) non-fasting cholesterol of +4.4 mg/dL at Week 24 (n=231) and +5.5 mg/dL at Week 48 (n=86); and (b) non-fasting triglycerides of +19.9 mg/dL at Week 24 (n=52).
Pooled data from 3 placebo-controlled, 3- to 6-week, fixed-dose studies in children and adolescents with schizophrenia (13–17 years of age), bipolar mania (10–17 years of age), or autistic disorder (5–17 years of age) are presented in Table 5.
Table 5.
Change in Fasting Lipids from Three Placebo-Controlled, 3- to 6-Week, Fixed-Dose Studies in Children and Adolescents with Schizophrenia (13–17 Years of Age), Bipolar Mania (10–17 Years of Age), or Autistic Disorder (5 to 17 Years of Age) Risperidone Tablets Placebo 0.5-6 mg/day Mean change from baseline (mg/dL) Cholesterol n=74 n=133 Change from baseline 0.3 -0.3 LDL n=22 n=22 Change from baseline 3.7 0.5 HDL n=22 n=22 Change from baseline 1.6 -1.9 Triglycerides n=77 n=138 Change from baseline -9.0 -2.6 Proportion of patients with shifts Cholesterol 2.4% 3.8% (<170 mg/dL to ≥200 mg/dL) (1/42) (3/80) LDL 0% 0% (<110 mg/dL to ≥130 mg/dL) (0/16) (0/16) HDL 0% 10% (≥40 mg/dL to <40 mg/dL) (0/19) (2/20) Triglycerides 1.5% 7.1% (<150 mg/dL to ≥200 mg/dL) (1/65) (8/113) In longer-term, uncontrolled, open-label extension pediatric studies, risperidone tablets were associated with a mean change in (a) fasting cholesterol of +2.1 mg/dL at Week 24 (n=114); (b) fasting LDL of -0.2 mg/dL at Week 24 (n=103); (c) fasting HDL of +0.4 mg/dL at Week 24 (n=103); and (d) fasting triglycerides of +6.8 mg/dL at Week 24 (n=120).
Weight Gain Weight gain has been observed with atypical antipsychotic use.
Clinical monitoring of weight is recommended.
Data on mean changes in body weight and the proportion of subjects meeting a weight gain criterion of 7% or greater of body weight from 7 placebo-controlled, 3- to 8- week, fixed- or flexible-dose studies in adult subjects with schizophrenia or bipolar mania are presented in Table 6.
Table 6.
Mean Change in Body Weight (kg) and the Proportion of Subjects with =7% Gain in Body Weight From Seven Placebo-Controlled, 3- to 8-Week, Fixed- or Flexible-Dose Studies in Adult Subjects With Schizophrenia or Bipolar Mania Risperidone Tablets Placebo (n=597) 1–8 mg/day (n=769) >8–16 mg/day (n=158) Weight (kg) Change from baseline -0.3 0.7 2.2 Weight Gain ≥7% increase from baseline 2.9% 8.7% 20.9% In longer-term, controlled and uncontrolled studies, risperidone tablets were associated with a mean change in weight of +4.3 kg at Week 24 (n=395) and +5.3 kg at Week 48 (n=203).
Data on mean changes in body weight and the proportion of subjects meeting the criterion of ≥7% gain in body weight from nine placebo-controlled, 3- to 8-week, fixed-dose studies in children and adolescents with schizophrenia (13–17 years of age), bipolar mania (10–17 years of age), autistic disorder (5–17 years of age), or other psychiatric disorders (5–17 years of age) are presented in Table 7.
Table 7.
Mean Change in Body Weight (kg) and the Proportion of Subjects With =7% Gain in Body Weight From Nine Placebo-Controlled, 3- to 8-Week, Fixed-Dose Studies in Children and Adolescents With Schizophrenia (13–17 Years of Age), Bipolar Mania (10–17 Years of Age), Autistic Disorder (5 to 17 Years of Age) or Other Psychiatric Disorders (5–17 Years of Age) Placebo Risperidone Tablets 0.5–6 mg/day (n=375) (n=448) Weight (kg) Change from baseline 0.6 2.0 Weight Gain ≥7% increase from baseline 6.9% 32.6% In longer-term, uncontrolled, open-label extension pediatric studies, risperidone tablets were associated with a mean change in weight of +5.5 kg at Week 24 (n=748) and +8.0 kg at Week 48 (n=242).
In a long-term, open-label extension study in adolescent patients with schizophrenia, weight increase was reported as a treatment-emergent adverse event in 14% of patients.
In 103 adolescent patients with schizophrenia, a mean increase of 9.0 kg was observed after 8 months of risperidone tablets treatment.
The majority of that increase was observed within the first 6 months.
The average percentiles at baseline and 8 months, respectively, were 56 and 72 for weight, 55 and 58 for height, and 51 and 71 for body mass index.
In long-term, open-label trials (studies in patients with autistic disorder or other psychiatric disorders), a mean increase of 7.5 kg after 12 months of risperidone tablets treatment was observed, which was higher than the expected normal weight gain (approximately 3 to 3.5 kg per year adjusted for age, based on Centers for Disease Control and Prevention normative data).
The majority of that increase occurred within the first 6 months of exposure to risperidone tablets.
The average percentiles at baseline and 12 months, respectively, were 49 and 60 for weight, 48 and 53 for height, and 50 and 62 for body mass index.
In one 3-week, placebo-controlled trial in children and adolescent patients with acute manic or mixed episodes of bipolar I disorder, increases in body weight were higher in the risperidone tablets groups than the placebo group, but not dose related (1.90 kg in the risperidone tablets 0.5–2.5 mg group, 1.44 kg in the risperidone tablets 3–6 mg group, and 0.65 kg in the placebo group).
A similar trend was observed in the mean change from baseline in body mass index.
When treating pediatric patients with risperidone tablets for any indication, weight gain should be assessed against that expected with normal growth.
5.6 Hyperprolactinemia As with other drugs that antagonize dopamine D 2 receptors, risperidone tablets elevates prolactin levels and the elevation persists during chronic administration.
Risperidone tablets are associated with higher levels of prolactin elevation than other antipsychotic agents.
Hyperprolactinemia may suppress hypothalamic GnRH, resulting in reduced pituitary gonadotropin secretion.
This, in turn, may inhibit reproductive function by impairing gonadal steroidogenesis in both female and male patients.
Galactorrhea, amenorrhea, gynecomastia, and impotence have been reported in patients receiving prolactin-elevating compounds.
Long-standing hyperprolactinemia when associated with hypogonadism may lead to decreased bone density in both female and male subjects.
Tissue culture experiments indicate that approximately one-third of human breast cancers are prolactin dependent in vitro , a factor of potential importance if the prescription of these drugs is contemplated in a patient with previously detected breast cancer.
An increase in pituitary gland, mammary gland, and pancreatic islet cell neoplasia (mammary adenocarcinomas, pituitary and pancreatic adenomas) was observed in the risperidone carcinogenicity studies conducted in mice and rats [see Nonclinical Toxicology (13.1) ] .
Neither clinical studies nor epidemiologic studies conducted to date have shown an association between chronic administration of this class of drugs and tumorigenesis in humans; the available evidence is considered too limited to be conclusive at this time.
5.7 Orthostatic Hypotension Risperidone tablets may induce orthostatic hypotension associated with dizziness, tachycardia, and in some patients, syncope, especially during the initial dose-titration period, probably reflecting its alpha-adrenergic antagonistic properties.
Syncope was reported in 0.2% (6/2607) of risperidone tablets-treated patients in Phase 2 and 3 studies in adults with schizophrenia.
The risk of orthostatic hypotension and syncope may be minimized by limiting the initial dose to 2 mg total (either once daily or 1 mg twice daily) in normal adults and 0.5 mg twice daily in the elderly and patients with renal or hepatic impairment [see Dosage and Administration ( 2.1 , 2.4 )] .
Monitoring of orthostatic vital signs should be considered in patients for whom this is of concern.
A dose reduction should be considered if hypotension occurs.
Risperidone tablets should be used with particular caution in patients with known cardiovascular disease (history of myocardial infarction or ischemia, heart failure, or conduction abnormalities), cerebrovascular disease, and conditions which would predispose patients to hypotension, e.g., dehydration and hypovolemia, and in the elderly and patients with renal or hepatic impairment.
Monitoring of orthostatic vital signs should be considered if hypotension occurs.
Clinically significant hypotension has been observed with concomitant use of risperidone tablets and antihypertensive medication.
5.8 Falls Somnolence, postural hypotension, motor and sensory instability have been reported with the use of antipsychotics, including risperidone tablets, which may lead to falls and, consequently, fractures or other fall-related injuries.
For patients, particularly the elderly, with diseases, conditions, or medications that could exacerbate these effects, assess the risk of falls when initiating antipsychotic treatment and recurrently for patients on long-term antipsychotic therapy.
5.9 Leukopenia, Neutropenia, and Agranulocytosis Class Effect : In clinical trial and/or postmarketing experience, events of leukopenia/neutropenia have been reported temporally related to antipsychotic agents, including risperidone tablets.
Agranulocytosis has also been reported.
Possible risk factors for leukopenia/neutropenia include pre-existing low white blood cell count (WBC) and history of drug-induced leukopenia/neutropenia.
Patients with a history of a clinically significant low WBC or a drug-induced leukopenia/neutropenia should have their complete blood count (CBC) monitored frequently during the first few months of therapy and discontinuation of risperidone tablets should be considered at the first sign of a clinically significant decline in WBC in the absence of other causative factors.
Patients with clinically significant neutropenia should be carefully monitored for fever or other symptoms or signs of infection and treated promptly if such symptoms or signs occur.
Patients with severe neutropenia (absolute neutrophil count <1000/mm 3 ) should discontinue risperidone tablets and have their WBC followed until recovery.
5.10 Potential for Cognitive and Motor Impairment Somnolence was a commonly reported adverse reactions associated with risperidone tablets treatment, especially when ascertained by direct questioning of patients.
This adverse reaction is dose-related, and in a study utilizing a checklist to detect adverse events, 41% of the high-dose patients (risperidone tablets 16 mg/day) reported somnolence compared to 16% of placebo patients.
Direct questioning is more sensitive for detecting adverse events than spontaneous reporting, by which 8% of risperidone tablets 16 mg/day patients and 1% of placebo patients reported somnolence as an adverse reation.
Since risperidone tablets have the potential to impair judgment, thinking, or motor skills, patients should be cautioned about operating hazardous machinery, including automobiles, until they are reasonably certain that risperidone tablets therapy does not affect them adversely.
5.11 Seizures During premarketing testing in adult patients with schizophrenia, seizures occurred in 0.3% (9/2607) of risperidone tablets-treated patients, two in association with hyponatremia.
Risperidone tablets should be used cautiously in patients with a history of seizures.
5.12 Dysphagia Esophageal dysmotility and aspiration have been associated with antipsychotic drug use.
Aspiration pneumonia is a common cause of morbidity and mortality in patients with advanced Alzheimer’s dementia.
Risperidone tablets and other antipsychotic drugs should be used cautiously in patients at risk for aspiration pneumonia.
[see Boxed Warning and Warnings and Precautions (5.1) ].
5.13 Priapism Priapism has been reported during postmarketing surveillance.
Severe priapism may require surgical intervention.
5.14 Body Temperature Regulation Disruption of body temperature regulation has been attributed to antipsychotic agents.
Both hyperthermia and hypothermia have been reported in association with oral risperidone tablets use.
Caution is advised when prescribing for patients who will be exposed to temperature extremes.
INFORMATION FOR PATIENTS
17 PATIENT COUNSELING INFORMATION Physicians are advised to discuss the following issues with patients for whom they prescribe risperidone tablets.
Neuroleptic Malignant Syndrome (NMS) Counsel patients about a potentially fatal adverse reaction, Neuroleptic Malignant Syndrome (NMS), that has been reported in association with administration of antipsychotic drugs.
Advise patients, family members, or caregivers to contact the healthcare provider or report to the emergency room if they experience signs and symptoms of NMS, including hyperpyrexia, muscle rigidity, altered mental status including delirium, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia) [see Warnings and Precautions ( 5.3 )] .
Tardive Dyskinesia Counsel patients on the signs and symptoms of tardive dyskinesia and to contact their healthcare provider if these abnormal movements occur [see Warnings and Precautions ( 5.4 )] .
Metabolic Changes Educate patients about the risk of metabolic changes, how to recognize symptoms of hyperglycemia and diabetes mellitus, and the need for specific monitoring, including blood glucose, lipids, and weight [see Warnings and Precautions ( 5.5 )] .
Orthostatic Hypotension Educate patients about the risk of orthostatic hypotension and syncope, particularly at the time of initiating treatment, re-initiating treatment, or increasing the dose [see Warnings and Precautions ( 5.7 )] .
Leukopenia/Neutropenia Advise patients with a pre-existing low WBC or a history of drug induced leukopenia/neutropenia they should have their CBC monitored while taking risperdione tablets [see Warnings and Precautions ( 5.9 )] .
Hyperprolactinemia Counsel patients on signs and symptoms of hyperprolactinemia that may be associated with chronic use of risperdione tablets.
Advise them to seek medical attention if they experience any of the following: amenorrhea or galactorrhea in females, erectile dysfunction or gynecomastia in males.
[See Warnings and Precautions ( 5.6 )] .
Interference with Cognitive and Motor Performance Caution patients about performing activities requiring mental alertness, such as operating hazardous machinery, or operating a motor vehicle until they are reasonably certain that risperdione tablets therapy does not affect them adversely [see Warnings and Precautions ( 5.10 )] .
Priapism Advise patients of the possibility of painful or prolonged penile erections (priapism).
Instruct the patient to seek immediate medical attention in the event of priapism [Warnings and Precautions ( 5.13 )] .
Heat Exposure and Dehydration Counsel patients regarding appropriate care in avoiding overheating and dehydration [see Warnings and Precautions ( 5.14 )] .
Concomitant Medication Advise patients to inform their healthcare providers if they are taking, or plan to take any prescription or over-the-counter drugs, as there is a potential for interactions [see Drug Interactions ( 7 )] .
Alcohol Advise patients to avoid alcohol while taking risperdione tablets [see Drug Interactions ( 7.2 )] .
Pregnancy Advise patients to notify their healthcare provider if they become pregnant or intend to become pregnant during treatment with risperdione tablets.
Advise patients that risperdione tablets may cause extrapyramidal and/or withdrawal symptoms in a neonate.
Advise patients that there is a pregnancy registry that monitors pregnancy outcomes in women exposed to risperdione tablets during pregnancy [see Use in Specific Populations ( 8.1 )] .
Lactation Advise breastfeeding women using risperdione tablets to monitor infants for somnolence, failure to thrive, jitteriness, and extrapyramidal symptoms (tremors and abnormal muscle movements) and to seek medical care if they notice these signs [see Use in Specific Populations ( 8.2 )] .
Infertility Advise females of reproductive potential that risperdione tablets may impair fertility due to an increase in serum prolactin levels.
The effects on fertility are reversible [see Use in Specific Populations ( 8.3 )].
Risperidone Tablets, USP Marketed by: Ajanta Pharma USA Inc.
Bridgewater, NJ 08807.
Made in India.
Revised: 02/2021
DOSAGE AND ADMINISTRATION
2 Table 1.
Recommended Daily Dosage by Indication Initial Dose Titration (Increments) Target Dose Effective Dose Range Schizophrenia: adults ( 2.1 ) 2 mg 1 to 2 mg 4 to 8 mg 4 to 16 mg Schizophrenia: adolescents ( 2.2 ) 0.5 mg 0.5 to 1 mg 3 mg 1 to 6 mg Bipolar mania: adults ( 2.2 ) 2 to 3 mg 1 mg 1 to 6 mg 1 to 6 mg Bipolar mania: children and adolescents ( 2.2 ) 0.5 mg 0.5 to 1 mg 1 to 2.5 mg 1 to 6 mg Irritability in autistic disorder ( 2.3 ) 0.25 mg Can increase to 0.5 mg by Day 4: (body weight less than 20 kg) 0.5 mg Can increase to 1 mg by Day 4: (body weight greater than or equal to 20 kg) After Day 4, at intervals of > 2 weeks: 0.25 mg (body weight less than 20 kg) 0.5 mg (body weight greater than or equal to 20 kg) 0.5 mg: (body weight less than 20 kg) 1 mg: (body weight greater than or equal to 20 kg) 0.5 to 3 mg Severe Renal and Hepatic Impairment in Adults: use a lower starting dose of 0.5 mg twice daily.
May increase to dosages above 1.5 mg twice daily at intervals of one week or longer.
Recommended daily dosage: Initial Dose Target Dose Effective Dose Range Schizophrenia: adults ( 2.1 ) 2 mg 4 to 8 mg 4 to 16 mg Schizophrenia: adolescents ( 2.1 ) 0.5 mg 3 mg 1 to 6 mg Bipolar mania: Adults ( 2.2 ) 2 to 3 mg 1 to 6 mg 1 to 6 mg Bipolar mania: in children and adolescents ( 2.2 ) 0.5 mg 1 to 2.5 mg 1 to 6 mg Irritability associated with autistic disorder ( 2.3 ) 0.25 mg (Weight < 20 kg) 0.5 mg (Weight ≥20 kg) 0.5 mg (<20 kg) 1 mg (≥20 kg) 0.5 to 3 mg Severe Renal or Hepatic Impairment in Adults: Use a lower starting dose of 0.5 mg twice daily.
May increase to dosages above 1.5 mg twice daily at intervals of at least one week.
( 2.4 ) 2.1 Schizophrenia Adults Usual Initial Dose Risperidone tablets can be administered once or twice daily.
Initial dosing is 2 mg per day.
May increase the dose at intervals of 24 hours or greater, in increments of 1 to 2 mg per day, as tolerated, to a recommended dose of 4 to 8 mg per day.
In some patients, slower titration may be appropriate.
Efficacy has been demonstrated in a range of 4 mg to 16 mg per day .
However, doses above 6 mg per day for twice daily dosing were not demonstrated to be more efficacious than lower doses, were associated with more extrapyramidal symptoms and other adverse effects, and are generally not recommended.
In a single study supporting once-daily dosing, the efficacy results were generally stronger for 8 mg than for 4 mg.
The safety of doses above 16 mg per day has not been evaluated in clinical trials [see Clinical Studies (14.1) ].
Adolescents The initial dose is 0.5 mg once daily, administered as a single-daily dose in the morning or evening.
The dose may be adjusted at intervals of 24 hours or greater, in increments of 0.5 mg or 1 mg per day, as tolerated, to a recommended dose of 3 mg per day.
Although efficacy has been demonstrated in studies of adolescent patients with schizophrenia at doses between 1 mg and 6 mg per day, no additional benefit was observed above 3 mg per day, and higher doses were associated with more adverse events.
Doses higher than 6 mg per day have not been studied.
Patients experiencing persistent somnolence may benefit from administering half the daily dose twice daily.
Maintenance Therapy While it is unknown how long a patient with schizophrenia should remain on risperidone tablets, the effectiveness of risperidone tablets 2 mg per day to 8 mg per day at delaying relapse was demonstrated in a controlled trial in adult patients who had been clinically stable for at least 4 weeks and were then followed for a period of 1 to 2 years [see Clinical Studies (14.1) ] .
Both adult and adolescent patients who respond acutely should generally be maintained on their effective dose beyond the acute episode.
Patients should be periodically reassessed to determine the need for maintenance treatment.
Reinitiation of Treatment in Patients Previously Discontinued Although there are no data to specifically address reinitiation of treatment, it is recommended that after an interval off risperidone tablets, the initial titration schedule should be followed.
Switching From Other Antipsychotics There are no systematically collected data to specifically address switching schizophrenic patients from other antipsychotics to risperidone tablets, or treating patients with concomitant antipsychotics.
2.2 Bipolar Mania Usual Dose Adults The inital dose range is 2 mg to 3 mg per day.
The dose may be adjusted at intervals of 24 hours or greater, in increments of 1 mg per day.
The effective dose range is 1 mg to 6 mg per day, as studied in the short-term, placebo-controlled trials.
In these trials, short-term (3 week) anti-manic efficacy was demonstrated in a flexible dosage range of 1 mg to 6 mg per day [see Clinical Studies (14.2 , 14.3) ] .
Risperidone tablets doses higher than 6 mg per day were not studied.
Pediatrics The inital dose is 0.5 mg once daily, administered as a single-daily dose in the morning or evening.
The dose may be adjusted at intervals of 24 hours or greater, in increments of 0.5 mg or 1 mg per day, as tolerated, to the recommended target dose of 1 mg to 2.5 mg per day.
Although efficacy has been demonstrated in studies of pediatric patients with bipolar mania at doses between 0.5 mg and 6 mg per day, no additional benefit was observed above 2.5 mg per day, and higher doses were associated with more adverse events.
Doses higher than 6 mg per day have not been studied.
Patients experiencing persistent somnolence may benefit from administering half the daily dose twice daily.
Maintenance Therapy There is no body of evidence available from controlled trials to guide a clinician in the longer-term management of a patient who improves during treatment of an acute manic episode with risperidone tablets.
While it is generally agreed that pharmacological treatment beyond an acute response in mania is desirable, both for maintenance of the initial response and for prevention of new manic episodes, there are no systematically obtained data to support the use of risperidone tablets in such longer-term treatment (i.e., beyond 3 weeks).
The physician who elects to use risperidone tablets for extended periods should periodically re-evaluate the long-term risks and benefits of the drug for the individual patient.
2.3 Irritability Associated with Autistic Disorder – Pediatrics (Children and Adolescents) The dosage of risperidone tablets should be individualized according to the response and tolerability of the patient.
The total daily dose of risperidone tablets can be administered once daily, or half the total daily dose can be administered twice daily.
For patients with body weight less than 20 kg, initiate dosing at 0.25 mg per day.
For patients with body weight greater than or equal to 20 kg, initiate dosing at 0.5 mg per day.
After a minimum of four days, the dose may be increased to the recommended dose of 0.5 mg per day for patients less than 20 kg and 1.0 mg per day for patients greater than or equal to 20 kg.
Maintain this dose for a minimum of 14 days.
In patients not achieving sufficient clinical response, the dose may be increased at intervals of 2 weeks or greater, in increments of 0.25 mg per day for patients less than 20 kg, or increments of 0.5 mg per day for patients greater than or equal to 20 kg.
The effective dose range is 0.5 mg to 3 mg per day.
No dosing data are available for children who weigh less than 15 kg.
Once sufficient clinical response has been achieved and maintained, consider gradually lowering the dose to achieve the optimal balance of efficacy and safety.
The physician who elects to use risperidone tablets for extended periods should periodically re-evaluate the long-term risks and benefits of the drug for the individual patient.
Patients experiencing persistent somnolence may benefit from a once-daily dose administered at bedtime or administering half the daily dose twice daily, or a reduction of the dose.
2.4 Dosing in Patients with Severe Renal or Hepatic Impairment For patients with severe renal impairment (Clcr < 30 mL/min) or hepatic impairment (10-15 points on Child Pugh System), the initial starting dose is 0.5 mg twice daily.
The dose may be increased in increments of 0.5 mg or less, administered twice daily.
For doses above 1.5 mg twice daily, increase in intervals of one week or greater [see Use in Specific Populations (8.6 and 8.7) ] .
2.5 Dose Adjustments for Specific Drug Interactions When risperidone tablets are co-administered with enzyme inducers (e.g., carbamazepine), the dose of risperidone tablets should be increased up to double the patient’s usual dose.
It may be necessary to decrease the risperidone tablets dose when enzyme inducers such as carbamazepine are discontinued [see Drug Interactions (7.1) ] .
Similar effect may be expected with co-administration of risperidone tablets with other enzyme inducers (e.g., phenytoin, rifampin, and phenobarbital).
When fluoxetine or paroxetine is co-administered with risperidone tablets, the dose of risperidone tablets should be reduced.
The risperidone tablets dose should not exceed 8 mg per day in adults when co-administered with these drugs.
When initiating therapy, risperidone tablets should be titrated slowly.
It may be necessary to increase the risperidone tablets dose when enzyme inhibitors such as fluoxetine or paroxetine are discontinued [see Drug Interactions (7.1) ] .