From the Guidelines
For tardive dyskinesia that does not resolve after antipsychotic discontinuation, the first-line treatment is a reversible inhibitor of the vesicular monoamine transporter 2 (VMAT2), as recommended by the American Psychiatric Association 1. This approach is based on the most recent and highest quality evidence available. The APA recommends (1B) that patients who have moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy be treated with a reversible inhibitor of the VMAT2. Some key points to consider when treating tardive dyskinesia include:
- Obtaining baseline abnormal involuntary movement scale (AIMS) scores to monitor effectiveness
- Continuing treatment long-term as TD symptoms often return when medication is stopped
- Regular monitoring of symptoms and adjusting treatment as needed
- Informing patients that complete resolution may not occur, but significant improvement is often possible with appropriate treatment It's also important to note that alternative options, such as clonazepam, ginkgo biloba, or amantadine, may be considered, but have less evidence supporting their use 1. Non-pharmacological approaches like botulinum toxin injections may also be helpful for focal dyskinesias. The American Academy of Child and Adolescent Psychiatry also emphasizes the importance of prevention and early detection of TD, as well as adequate informed consent and baseline measures of abnormal movements 1.
From the FDA Drug Label
The change from baseline in the AIMS total dyskinesia score in the 80 mg INGREZZA group was statistically significantly different from the change in the placebo group. The AIMS total score for patients receiving AUSTEDO demonstrated statistically significant improvement, from baseline to Week 12, of 3.3 and 3.2 units for the 36 mg and 24 mg arms, respectively, compared with 1. 4 units in placebo
Treatment for Tardive Dyskinesia:
- Valbenazine (INGREZZA): is effective in treating tardive dyskinesia, with a statistically significant improvement in the AIMS total dyskinesia score compared to placebo 2.
- Deutetrabenazine (AUSTEDO): is also effective in treating tardive dyskinesia, with a statistically significant improvement in the AIMS total score compared to placebo 3. For patients with tardive dyskinesia that does not resolve after antipsychotic is stopped, valbenazine or deutetrabenazine can be considered as a treatment option.
From the Research
Treatment Options for Tardive Dyskinesia
- The first-line management of tardive dyskinesia is the withdrawal of antipsychotic medication if clinically feasible 4.
- For patients who cannot stop taking antipsychotics, switching to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine, may be effective in reducing symptoms 4.
- VMAT2 inhibitors, such as deutetrabenazine and valbenazine, have shown efficacy in reducing tardive dyskinesia symptoms and may be considered as a next-line option 4, 5, 6, 7, 8.
Efficacy of Deutetrabenazine and Valbenazine
- Deutetrabenazine and valbenazine have been shown to be effective in decreasing Abnormal Involuntary Movement Scale (AIMS) scores, with response rates ranging from 33% to 50% 5, 7, 8.
- The number needed to treat (NNT) for deutetrabenazine has been reported to be 5-7, indicating that 5-7 patients need to be treated to achieve a significant response in one patient 7.
- Valbenazine 40-80 mg and deutetrabenazine 12-36 mg per day have been evaluated for the treatment of tardive dyskinesia, with similar declines in AIMS scores 5.
Safety and Tolerability
- Deutetrabenazine and valbenazine have been shown to be well tolerated, with somnolence and akathisia reported as the most common adverse events 5, 7.
- The number needed to harm (NNH) for deutetrabenazine has been reported to be 189, indicating that 189 patients need to be treated to cause a significant adverse event in one patient 7.