What is the treatment for tardive dyskinesia?

Treatment for Tardive Dyskinesia

The most effective treatment approach for tardive dyskinesia (TD) involves discontinuing the causative antipsychotic medication when clinically feasible, switching to an atypical antipsychotic with lower D2 affinity if discontinuation is not possible, and considering VMAT-2 inhibitors (valbenazine or deutetrabenazine) as specific pharmacological interventions. 1, 2

Management Algorithm

First-Line Approaches:

1. Prevention strategies:

   • Use antipsychotics only for specific indications
   • Use minimum effective doses
   • Minimize duration of therapy
   • Regular monitoring with standardized scales (AIMS every 3-6 months) 1

2. When TD is detected:

   • Discontinue the causative antipsychotic if clinically feasible 1, 2, 3
   • If discontinuation is not possible due to risk of psychiatric relapse:
     • Switch to an atypical antipsychotic with lower D2 affinity (clozapine or quetiapine) 1, 2
     • Consider dose reduction of the current antipsychotic (contrary to some beliefs, dose reduction typically improves rather than worsens TD) 3

3. Specific pharmacological interventions:

   • VMAT-2 inhibitors have the strongest evidence for efficacy:
     • Valbenazine: FDA-approved, demonstrated significant improvement in AIMS scores 4
     • Deutetrabenazine: FDA-approved, demonstrated statistically significant improvement in AIMS total score 5

Second-Line Approaches:

• Beta-blockers may provide some relief 6
• Benzodiazepines have shown limited efficacy 6
• Vitamin E (tocopherol) may be beneficial in some cases 7, 8

Approaches to Avoid:

• Anticholinergic medications are generally not recommended as primary treatment for TD and may potentially worsen symptoms 1
• Increasing doses of typical antipsychotics may provide short-term suppression but long-term efficacy and risks have not been well studied 7

Special Considerations

Monitoring:

• Use the Abnormal Involuntary Movement Scale (AIMS) for baseline assessment and regular monitoring (every 3-6 months) 1
• Record baseline measures of abnormal movements before starting antipsychotic therapy 6

High-Risk Populations:

• Children and adolescents: TD point prevalence 5-20% with higher rates for typical antipsychotics 9
• Elderly patients: increased risk (up to 50% after 2 years of continuous typical antipsychotic use) 1
• Risk factors include: treatment with typical antipsychotics, higher doses, longer duration of exposure, older age, female gender, higher baseline AIMS scores, intellectual impairment 9

Tardive Dystonia:

• Characterized by slow movements along the body axis culminating in spasms
• Management approach similar to TD 6
• Botulinum toxin may be particularly effective 7

Clinical Pitfalls to Avoid

• Misdiagnosis: Akathisia is often misdiagnosed as psychotic agitation or anxiety 1
• Confusing withdrawal dyskinesia with TD: Withdrawal dyskinesia occurs with cessation of neuroleptics and typically resolves over time, unlike true TD which may persist 6, 1
• Underdiagnosis: Clinical database analyses suggest TD is underdiagnosed in practice (around 1% vs. expected 5-20%) 9
• Inadequate monitoring: Regular assessment with standardized scales is essential for early detection 1

Remember that prevention remains the best strategy, and the concern over TD should be balanced against the potential benefits provided by antipsychotics for patients with serious mental illness 6, 2.