How are tardive dyskinesia symptoms managed?

Management of Tardive Dyskinesia Symptoms

The most effective approach to managing tardive dyskinesia is to switch to an atypical antipsychotic with lower D2 receptor affinity (like clozapine or quetiapine) if discontinuation is not possible, or to use VMAT inhibitors such as valbenazine or deutetrabenazine which have FDA approval specifically for tardive dyskinesia treatment. 1, 2, 3, 4

Understanding Tardive Dyskinesia

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

• Athetoid or choreiform movements primarily in the orofacial region
• Can affect any part of the body
• Typically associated with long-term use of dopamine receptor antagonists (antipsychotics)
• Occurs in up to 50% of patients receiving neuroleptics 1

Prevention and Early Detection

Prevention is the primary strategy:

• Limit antipsychotic prescriptions to specific indications
• Use minimum effective doses
• Minimize duration of therapy
• Regular monitoring with standardized scales (AIMS every 3-6 months)
• Baseline assessment of abnormal movements before starting antipsychotics 1

Management Algorithm

Step 1: Assess the Need for Continued Antipsychotic Treatment

• If clinically feasible, discontinue the offending antipsychotic
• Note: Withdrawal dyskinesias may occur but typically resolve over time, unlike persistent TD 1

Step 2: If Antipsychotic Cannot Be Discontinued

1. Switch to atypical antipsychotics with lower D2 affinity:

   • Clozapine
   • Quetiapine
   • Olanzapine 4, 5

2. Consider FDA-approved VMAT inhibitors:

   • Valbenazine (INGREZZA)

     • Starting dose: 40mg daily
     • Target dose: 80mg daily
     • Demonstrated significant improvement in AIMS scores compared to placebo 2

   • Deutetrabenazine (AUSTEDO)

     • Starting dose: 12mg daily
     • Titrate by 6mg weekly increments
     • Target dose: 24-36mg daily (divided doses)
     • Demonstrated significant improvement in AIMS scores compared to placebo 3

Step 3: Dose Adjustments and Special Considerations

• For valbenazine: Reduce dose in CYP2D6 poor metabolizers 2
• For both medications: Monitor for side effects including somnolence, QT prolongation
• Avoid abrupt withdrawal of antipsychotics as this may worsen TD symptoms 1

Special Considerations

Tardive Dystonia

• Often coexists with TD
• Characterized by sustained, stereotyped muscle spasms of a twisting nature
• Management approach similar to TD 1, 5

Monitoring Response

• Use AIMS scale to objectively track improvement
• Assess at regular intervals (every 3 months)
• Continue monitoring even after switching medications 1

Common Pitfalls to Avoid

1. Misdiagnosis: TD is often confused with other movement disorders or psychotic agitation 1

2. Inappropriate medication adjustments: Abrupt discontinuation of antipsychotics can worsen TD symptoms 1

3. Inadequate monitoring: Without specific training and monitoring systems, TD movements may be missed 6

4. False reassurance with clozapine: While clozapine may suppress TD symptoms, evidence suggests this may be temporary rather than permanent resolution 7

5. Overlooking TD caused by non-psychiatric medications: Anti-emetics like metoclopramide, prochlorperazine, and promethazine can also cause TD 5

The management of tardive dyskinesia requires balancing the need for antipsychotic treatment with the risk of worsening movement disorders. The introduction of VMAT inhibitors has significantly improved treatment options, offering specific targeted therapy for TD symptoms while allowing continued antipsychotic treatment when necessary.