What are the management options for tardive dyskinesia (TD)?

From the Guidelines

Tardive dyskinesia (TD) is typically worsened by long-term use of neuroleptics, and management should prioritize discontinuation or dose reduction of the causative agent when possible, as well as consideration of alternative treatments such as VMAT2 inhibitors, as recommended by the American Psychiatric Association 1. The primary factors that exacerbate TD include:

• Long-term use of neuroleptics, such as antipsychotics or metoclopramide
• Sudden cessation of neuroleptic agents, which can lead to withdrawal dyskinesia
• Inadequate informed consent and baseline measures of abnormal movements
• Failure to regularly assess for dyskinesias, ideally every 3 to 6 months using standardized rating scales like the Abnormal Involuntary Movement Scale (AIMS) 1 Key management options for TD include:
• Discontinuation or dose reduction of the causative agent when possible
• Switching to alternative antipsychotics with lower risk of causing or worsening TD, such as clozapine or quetiapine
• Use of VMAT2 inhibitors, such as valbenazine, deutetrabenazine, or tetrabenazine, which have been shown to be effective in reducing abnormal movements 1
• Regular monitoring and patient education to manage expectations and track progress It is essential to note that complete symptom resolution may not always be achievable, and improvement may take weeks to months after starting treatment. Therefore, a comprehensive and person-centered treatment plan should be developed, incorporating evidence-based nonpharmacological and pharmacological treatments, as recommended by the American Psychiatric Association 1.

From the FDA Drug Label

Both the risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase. The syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses

The factors that make tardive dyskinesia worse include:

• Longer treatment duration: The risk of developing tardive dyskinesia increases with longer treatment duration.
• Higher cumulative dose: The risk of developing tardive dyskinesia also increases with higher cumulative doses of antipsychotic drugs. The management options for tardive dyskinesia (TD) include:
• Discontinuation of antipsychotic treatment: If signs and symptoms of tardive dyskinesia appear, discontinuation of antipsychotic treatment should be considered.
• Dose reduction: Reducing the dose of antipsychotic medication may help minimize the risk of developing tardive dyskinesia.
• Alternative treatments: Alternative treatments should be considered for patients who require chronic antipsychotic treatment, especially if they are at high risk of developing tardive dyskinesia 2, 3, 3.

From the Research

Factors that Exacerbate Tardive Dyskinesia

• The use of antipsychotic medication, particularly first-generation antipsychotics, can increase the risk of developing tardive dyskinesia 4, 5, 6
• The duration and dose of antipsychotic medication can also contribute to the development and severity of tardive dyskinesia 4, 5, 6
• Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity may help reduce symptoms of tardive dyskinesia 4

Management Options for Tardive Dyskinesia

• Preventing tardive dyskinesia is of primary importance, and clinicians should follow best practice for prescribing antipsychotic medication, including limiting the prescription for specific indications, using the minimum effective dose, and minimising the duration of therapy 4
• The first-line management of tardive dyskinesia is the withdrawal of antipsychotic medication if clinically feasible 4
• The use of vesicular monoamine transporter-2 (VMAT2) inhibitors, such as deutetrabenazine and valbenazine, has been shown to be effective in reducing symptoms of tardive dyskinesia 4, 7, 8
• Other treatment approaches, such as deep brain stimulation and repetitive transcranial magnetic stimulation, are being explored, but more research is needed to determine their effectiveness 8

Assessment and Diagnosis of Tardive Dyskinesia

• An accurate and early diagnosis of tardive dyskinesia is crucial, as the risk of permanence increases over time 7
• Clinicians should use a structured evaluative tool, such as the Abnormal Involuntary Movement Scale (AIMS), to assess patients for tardive dyskinesia 7, 5
• Patients and caregivers should be educated about the risks of and alternatives to antipsychotic medication and early signs of tardive dyskinesia 7