How is tardive dyskinesia (involuntary repetitive body movements) treated?

Treatment of Tardive Dyskinesia

The primary treatment for tardive dyskinesia is prevention, early detection, and if possible, discontinuation of the causative antipsychotic medication or switching to an atypical antipsychotic with lower risk of TD, such as clozapine or quetiapine. 1

Understanding Tardive Dyskinesia

Tardive dyskinesia (TD) is an involuntary movement disorder typically characterized by:

• Choreiform or athetoid movements in the orofacial region (tongue, lips, face)
• May also affect the trunk and extremities
• Associated with long-term use of dopamine receptor blocking agents (primarily antipsychotics)
• Potentially irreversible even after medication discontinuation

TD affects approximately 20% of patients on long-term neuroleptic therapy, with higher rates (up to 50%) in youth and other high-risk populations 1, 2.

Risk Factors

Several factors increase the risk of developing TD:

• Advanced age
• Female sex
• Affective disorders
• Non-psychotic diagnoses
• Longer duration of antipsychotic exposure
• Higher cumulative dose of antipsychotics
• Use of first-generation (typical) antipsychotics 2

Prevention Strategies

Prevention is crucial since TD can be irreversible:

1. Use antipsychotics only when clearly indicated
2. Prescribe the lowest effective dose
3. Minimize duration of therapy when possible
4. Consider atypical antipsychotics with lower TD risk
5. Perform regular monitoring for early signs of TD (every 3-6 months) using the Abnormal Involuntary Movement Scale (AIMS) 1, 3

Treatment Algorithm

When TD is detected:

Step 1: Evaluate and Confirm Diagnosis

• Conduct thorough assessment using AIMS
• Rule out other movement disorders
• Review medication history to confirm association with dopamine receptor blockers

Step 2: Review Primary Diagnosis

• Reassess the need for continued antipsychotic therapy
• Consider if the original indication still warrants treatment

Step 3: Medication Management

1. If clinically feasible, discontinue the offending medication

   • Note: Abrupt discontinuation may worsen TD symptoms temporarily
   • Gradual tapering is recommended 4

2. If antipsychotic therapy must continue:

   • Switch to an atypical antipsychotic with lower TD risk:
     • Clozapine has the lowest risk 4
     • Quetiapine is also associated with lower risk 5
     • Olanzapine may be considered 4
   • Avoid typical antipsychotics which have "significant, often severe side effects" and "inherent risk of irreversible tardive dyskinesia" 1

3. If TD persists despite above measures:

   • Consider VMAT2 inhibitors (deutetrabenazine or valbenazine) which have the strongest evidence for treating persistent TD 5, 3
   • Note: These medications may not be available in all countries

Step 4: Monitoring and Follow-up

• Continue regular AIMS assessments
• Monitor for improvement or worsening of symptoms
• Adjust treatment plan accordingly

Special Considerations

Tardive Dystonia

• Characterized by sustained, stereotyped muscle spasms
• Often more disabling than classic TD
• Treatment approach similar to TD 1, 4

Antipsychotic Selection

When antipsychotic therapy is necessary, consider risk profiles:

• Atypical antipsychotics (recommended):

  • Risperidone: Initial 0.25 mg/day; max 2-3 mg/day (extrapyramidal symptoms may occur at doses ≥2 mg/day)
  • Olanzapine: Initial 2.5 mg/day; max 10 mg/day
  • Quetiapine: Initial 12.5 mg twice daily; max 200 mg twice daily 1

• Typical antipsychotics (avoid if possible):

  • Associated with 50% risk of TD after 2 years of continuous use in elderly patients
  • Should be considered second-line therapy only when patients cannot tolerate or do not respond to atypical agents 1

Important Cautions

• TD may persist indefinitely even after medication discontinuation
• Withdrawal dyskinesias may temporarily worsen symptoms but generally resolve over time
• Antipsychotic benefits must be carefully weighed against TD risk, especially in non-psychotic conditions
• Be aware that antiemetics with dopamine-blocking properties (prochlorperazine, promethazine, metoclopramide) can also cause TD 4

Remember that early detection and intervention provide the best chance for improvement or resolution of TD symptoms 2.