The purpose of this trial is to determine if paliperidone ER is an effective treatment for adults with schizophrenia.

Paliperidone is being developed as a new therapeutic agent for the treatment of schizophrenia. The extended-release (ER) formulation of paliperidone was developed to deliver paliperidone at a relatively constant rate over a 24-hour period to improve the tolerability profile and decrease the potential for orthostatic hypotension. This study is designed to evaluate the efficacy, safety and tolerability of 2 fixed dosages of paliperidone ER compared with placebo in adult patients with schizophrenia. This is a multicenter, double-blind (neither the patient nor the physician will know if placebo or drug is being given and at what dose), randomized (patients will be assigned to different treatment groups based solely on chance), placebo- and active-controlled, parallel-group, dose-response study. Patients will be randomized into 1 of 4 treatment groups to receive oral dosages of paliperidone ER 6 mg or 12 mg, olanzapine 10 mg, or placebo once daily for a 6-week period. The study includes a screening period of up to 5 days, followed by 6-week double-blind treatment phase. Following the double-blind treatment phase, eligible patients (those who have completed the 6-week double-blind phase or who discontinue due to lack of efficacy after a minimum of 21 days) may enter a 52-week open-label extension phase with paliperidone ER monotherapy. While patients are hospitalized, efficacy will be assessed twice during the first week and at the end of the second week, and after patients are discharged from the hospital, they will return to have efficacy and safety assessments performed on a weekly basis through the end of the 6-week double-blind phase. Efficacy will be evaluated throughout the 6-week double-blind phase by completion of the Positive and Negative Syndrome Scale (PANSS), Clinical Global Impression Scale - Severity (CGI-S), Personal and Social Performance Scale (PSP), Schizophrenia Quality of Life Scale, Revision 4 (SQLS-R4), and Sleep Visual Analog Scale (VAS). The efficacy response will be measured by the change from baseline score to end of double-blind phase for PANSS, PSP, CGI-S, SQLS-R4, and Sleep VAS. Safety will be monitored throughout the study and includes assessments of the incidence of adverse events; measurement of extrapyramidal symptoms using 3 rating scales (Abnormal Involuntary Movement Scale [AIMS], Barnes Akathisia Rating Scale [BARS], Simpson-Angus Rating Scale [SAS]); measurement of vital signs (laying down and standing blood pressure, pulse, temperature); electrocardiograms; and clinical laboratory tests.

Double-blind: 6 mg or 12 mg fixed dose of paliperidone ER, olanzapine 10 mg or matching placebo taken orally once daily for 6 weeks. Open-label extension: start on paliperidone ER 9 mg taken orally once daily; maintained on a flexible dosage of paliperidone ER (3, 6, 9, or 12 mg/day) for 52 weeks.

• Janicak PG, Wu JH, Mao L. Hospitalization rates before and after initiation of paliperidone ER in patients with schizophrenia: results from open-label extensions of the US double-blind trials. Curr Med Res Opin. 2008 Jun;24(6):1807-15.
• Meltzer HY, Bobo WV, Nuamah IF, Lane R, Hough D, Kramer M, Eerdekens M. Efficacy and Tolerability of Oral Paliperidone Extended-Release Tablets in the Treatment of Acute Schizophrenia: Pooled Data From Three 6-Week, Placebo-Controlled Studies. J Clin Psychiatry. 2008 May 6;:e1-e13 [Epub ahead of print]

Inclusion Criteria:

• Double-blind phase: DSM-IV diagnosis of schizophrenia for at least 1 year
• Experiencing an acute episode, with a total PANSS score at screening between 70 and 120
• Agree to voluntary hospitalization for a minimum of 14 days. Open-label phase: must have completed the 6 weeks of double-blind treatment or completed at least 21 days of treatment and discontinued due to lack of efficacy

Exclusion Criteria:

• DSM-IV axis I diagnosis other than schizophrenia
• DSM-IV diagnosis of substance dependence within 6 months prior to screening evaluation (nicotine and caffeine dependence are not exclusionary)
• History of neuroleptic malignant syndrome (NMS)
• History of any severe preexisting gastrointestinal narrowing (pathologic or iatrogenic)
• Previous history of lack of response to risperidone when acutely psychotic
• Significant risk of suicidal or violent behavior