What is the treatment for Tardive Dyskinesia (TD)?

From the Guidelines

The most effective treatment for Tardive Dyskinesia (TD) is the use of reversible inhibitors of the vesicular monoamine transporter 2 (VMAT2), such as valbenazine or deutetrabenazine, as recommended by the American Psychiatric Association 1. Tardive dyskinesia is a neurological disorder characterized by involuntary, repetitive movements, typically affecting the face, mouth, and tongue, but sometimes involving the trunk and extremities. It's primarily caused by long-term use of dopamine receptor blocking agents, especially first-generation antipsychotics like haloperidol, but can also occur with second-generation antipsychotics and certain other medications.

Key Considerations

• Management includes medication adjustment when possible, with consideration of switching to antipsychotics with lower risk profiles such as quetiapine or clozapine.
• Prevention strategies include using the lowest effective dose of antipsychotics, regular monitoring for early symptoms, and considering alternative treatments when appropriate.
• Once established, tardive dyskinesia can be persistent even after medication discontinuation, highlighting the importance of early recognition and intervention.

Treatment Options

• Valbenazine (40-80mg daily) and deutetrabenazine (12-48mg daily in divided doses) are FDA-approved options for the treatment of TD, as they work by inhibiting VMAT2 and reducing abnormal dopamine signaling that causes the movements 1.
• The American Psychiatric Association recommends the use of reversible VMAT2 inhibitors for patients with moderate to severe or disabling TD associated with antipsychotic therapy 1.

Monitoring and Prevention

• Regular monitoring for early symptoms of TD is crucial, and the Abnormal Involuntary Movement Scale (AIMS) is a useful measure for monitoring this problem 1.
• Baseline measures of abnormal movements should be recorded, and assessment for dyskinesias should occur at least every 3 to 6 months 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 The efficacy of INGREZZA SPRINKLE has been established from adequate and well-controlled studies of INGREZZA for the treatment of tardive dyskinesia 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

The treatment for Tardive Dyskinesia (TD) is:

• Deutetrabenazine (AUSTEDO): The recommended dose is 12 mg per day, with increases allowed in 6-mg increments at 1-week intervals until satisfactory control of dyskinesia is achieved, until intolerable side effects occur, or until a maximal dose of 48 mg per day is reached 2
• Valbenazine (INGREZZA): The recommended dose is 40 mg or 80 mg per day 3

From the Research

Treatment Options for Tardive Dyskinesia (TD)

The treatment for TD is primarily focused on prevention, prompt detection, and management of early and potentially reversible cases 4. If a patient develops dyskinesia while taking an antipsychotic drug (APD), ideal management is immediate discontinuation of the APD, if this is psychiatrically feasible.

Non-Pharmacological Interventions

• Reducing the neuroleptic dose or switching to an atypical agent may be recommended for mild TD 5, 6.
• Discontinuing antipsychotic treatment altogether in the hope of facilitating remission is also an option 4, 6.

Pharmacological Interventions

• For mild dyskinesia, low doses of a benzodiazepine (e.g., clonazepam) may reduce the amount of both dyskinesia and associated anxiety 4.
• Tetrabenazine and reserpine are presynaptic dopamine depletors that may have considerable efficacy in TD, especially tardive dystonia; however, their use is often limited by side effects 4, 5.
• VMAT2 inhibitors, such as deutetrabenazine and valbenazine, are considered the treatment of choice for most patients with TD 7.
• Botulinum toxin injections are of considerable value in managing localized forms of tardive dystonia, such as retrocollis or blepharospasm 4.

Other Treatment Options

• Anticholinergic drugs are unhelpful and may aggravate TD, but may be effective in tardive dystonia 4.
• Vitamin E has been used for treatment of TD, with mixed results 4.
• Amantadine, Gingko biloba, zolpidem, and deep brain stimulation are other treatment options that have been discussed in the literature 7, 8.