From the Guidelines
Treatment of tardive dyskinesia primarily involves discontinuing the causative medication, typically antipsychotics, when clinically feasible, and considering FDA-approved medications such as valbenazine or deutetrabenazine, as recommended by the American Psychiatric Association 1.
Overview of Tardive Dyskinesia
Tardive dyskinesia (TD) is a major public health concern in the treatment of schizophrenia, characterized by involuntary movements, typically in the orofacial region, associated with long-term use of neuroleptics 1. The condition can significantly impact the quality of life and may persist even after discontinuation of the antipsychotic agent.
Assessment and Treatment
The American Psychiatric Association recommends a comprehensive treatment plan for patients with schizophrenia, including evidence-based nonpharmacological and pharmacological treatments 1. For patients with TD, the treatment plan should focus on discontinuing the causative medication, if possible, and considering alternative antipsychotic medications with lower risk profiles, such as atypical antipsychotics like quetiapine or clozapine.
Pharmacological Interventions
FDA-approved medications for TD include valbenazine (40-80 mg daily) and deutetrabenazine (12-48 mg daily in divided doses), which are vesicular monoamine transporter 2 (VMAT2) inhibitors that reduce dopamine release in the brain 1. These medications have shown improvement in symptoms within 4-6 weeks of treatment. Alternative options with less evidence include tetrabenazine, clonazepam, ginkgo biloba, and vitamin E.
Monitoring and Prevention
Regular monitoring for symptom improvement using standardized rating scales like the Abnormal Involuntary Movement Scale (AIMS) is essential 1. Prevention is crucial by using the lowest effective dose of antipsychotics for the shortest duration necessary and conducting regular screenings for early signs of TD in patients on long-term antipsychotic therapy.
Key Recommendations
- Discontinue the causative medication, if clinically feasible 1.
- Consider switching to a lower-risk atypical antipsychotic 1.
- Use FDA-approved medications like valbenazine or deutetrabenazine for TD treatment 1.
- Monitor symptoms regularly using standardized rating scales 1.
- Implement preventive measures, such as using the lowest effective dose of antipsychotics and conducting regular screenings for early signs of TD 1.
From the FDA Drug Label
The efficacy of AUSTEDO in the treatment for tardive dyskinesia was established in two 12‑week, randomized, double-blind, placebo-controlled, multi-center trials conducted in 335 adult ambulatory patients with tardive dyskinesia caused by use of dopamine receptor antagonists The Abnormal Involuntary Movement Scale (AIMS) was the primary efficacy measure for the assessment of tardive dyskinesia severity In Study 1, 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 A randomized, double-blind, placebo-controlled trial of INGREZZA was conducted in patients with moderate to severe tardive dyskinesia as determined by clinical observation. 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.
Treatment of Tardive Dyskinesia:
- Deutetrabenazine (AUSTEDO) and valbenazine (INGREZZA) are effective treatments for tardive dyskinesia.
- The primary efficacy measure for the assessment of tardive dyskinesia severity is the Abnormal Involuntary Movement Scale (AIMS).
- Statistically significant improvements in AIMS total score were observed with deutetrabenazine (3.3 and 3.2 units for the 36 mg and 24 mg arms, respectively) and valbenazine (80 mg group) compared to placebo.
- Deutetrabenazine and valbenazine can be used to treat tardive dyskinesia in adult patients, with dosing regimens as described in the respective drug labels 2 3.
From the Research
Treatment Options for Tardive Dyskinesia
- The primary approach to managing tardive dyskinesia is prevention, which involves careful prescribing of antipsychotic medication, using the minimum effective dose, and minimizing the duration of therapy 4, 5.
- If a patient develops dyskinesia while taking an antipsychotic drug, ideal management is immediate discontinuation of the drug, if clinically feasible 4, 5.
- Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine, may be effective in reducing tardive dyskinesia symptoms 5.
- The strongest evidence for a suitable co-intervention to treat tardive dyskinesia comes from tests with the new VMAT inhibitors, deutetrabenazine and valbenazine 5, 6, 7, 8.
Vesicular Monoamine Transporter 2 (VMAT2) Inhibitors
- VMAT2 inhibitors, including tetrabenazine, deutetrabenazine, and valbenazine, are considered the treatment of choice for most patients with tardive dyskinesia 6.
- Deutetrabenazine and valbenazine have been shown to be effective in decreasing Abnormal Involuntary Movement Scale (AIMS) scores and are well tolerated in randomized controlled trials 7, 8.
- These medications deplete presynaptic dopamine and reduce involuntary movements in many hyperkinetic movement disorders, particularly tardive dyskinesia, Huntington disease, and Tourette syndrome 6.
Other Treatment Options
- For mild dyskinesia, low doses of a benzodiazepine (e.g., clonazepam) may reduce the amount of both dyskinesia and associated anxiety 4.
- Anticholinergic drugs are unhelpful and may aggravate tardive dyskinesia, but may be effective in tardive dystonia 4.
- Botulinum toxin injections are of considerable value in managing localized forms of tardive dystonia, such as retrocollis or blepharospasm 4.