How is tardive dyskinesia best managed?

Management of Tardive Dyskinesia

The best approach to managing tardive dyskinesia is prevention first, followed by discontinuation of the causative agent when possible, switching to a lower-risk antipsychotic if discontinuation isn't feasible, and considering VMAT-2 inhibitors like deutetrabenazine for persistent symptoms. 1

Prevention Strategies

• Use antipsychotics only for specific indications
• Prescribe the minimum effective dose
• Minimize duration of therapy when possible
• Perform baseline assessment of abnormal movements before starting antipsychotics
• Monitor regularly with standardized scales (e.g., AIMS every 3-6 months) 1

Management Algorithm for Established TD

Step 1: Discontinue or Reduce Causative Agent

• If clinically feasible, withdraw the antipsychotic medication 1, 2
• Avoid abrupt cessation as this may worsen TD symptoms 3
• Gradual dose reduction of conventional antipsychotics tends to improve rather than exacerbate TD 4

Step 2: If Antipsychotic Cannot Be Discontinued

• Switch from first-generation to second-generation antipsychotic with lower D2 affinity 1, 2
• Clozapine and quetiapine have shown the greatest benefit for reducing TD symptoms 2, 3

Step 3: Pharmacological Interventions for Persistent TD

1. VMAT-2 Inhibitors (First-line):

   • Deutetrabenazine (AUSTEDO) - FDA approved with strong evidence
     • Demonstrated significant improvement in AIMS scores in clinical trials
     • 42% of patients rated as "Much Improved" or "Very Much Improved" vs. 13% with placebo 5
     • Dosing: Start at 12 mg/day and titrate by 6 mg weekly to optimal dose (up to 48 mg/day) 5

2. Second-line options (when VMAT-2 inhibitors unavailable/contraindicated):

   • Benzodiazepines - limited efficacy 1
   • Beta-blockers - may provide some relief 1
   • Amantadine 3

Special Considerations

Managing Coexisting Movement Disorders

• For acute dystonia: Anticholinergics (benztropine, trihexyphenidyl) or antihistamines 1
• For drug-induced parkinsonism: Anticholinergics (benztropine 1-2 mg daily, max 6 mg) or amantadine 1
• For akathisia: Beta-blockers (propranolol, metoprolol) as first-line, benzodiazepines as alternative 1

Caution with Anticholinergics

• Anticholinergics have limited efficacy for TD and may actually worsen symptoms 1
• Only use for coexisting conditions like drug-induced parkinsonism
• Monitor for adverse effects: confusion, visual hallucinations, urinary retention, cognitive effects 1

High-Risk Populations

• Children and adolescents: Up to 50% receiving neuroleptics may experience tardive or withdrawal dyskinesia 1, 6
• Elderly patients: Increased risk (up to 50% after 2 years of continuous typical antipsychotic use) 1
• Risk factors: Female gender, higher doses, longer duration of exposure, intellectual impairment 6

Monitoring and Follow-up

• Use Abnormal Involuntary Movement Scale (AIMS) for baseline and follow-up assessments
• Assess for dyskinesias at least every 3-6 months during antipsychotic therapy 7, 1
• Document informed consent regarding TD risk when initiating antipsychotics 1

Treatment-Resistant Cases

• For focal symptoms (e.g., tongue protrusion, blepharospasm), consider botulinum toxin injections 3
• As a last resort for disabling, life-threatening TD that persists despite other interventions, some experts suggest resuming treatment with the antipsychotic to suppress symptoms, though this may worsen TD long-term 3

Remember that TD may persist even after discontinuation of the causative medication, and withdrawal dyskinesia (which typically resolves over time) should be distinguished from true TD 7, 1.