What is the treatment for tardive dyskinesia?

Treatment of Tardive Dyskinesia

The first-line treatment for tardive dyskinesia (TD) is discontinuation of the causative antipsychotic medication if clinically feasible, followed by switching to an atypical antipsychotic with lower D2 affinity if discontinuation is not possible, and using VMAT2 inhibitors (valbenazine or deutetrabenazine) when symptoms persist. 1

Management Algorithm

1. Prevention

   • Use antipsychotics only when necessary
   • Use lowest effective dose
   • Minimize duration of therapy
   • Prefer atypical antipsychotics over typical ones
   • Regular monitoring with AIMS assessments (every 3-6 months)

2. When TD is diagnosed:

   Step 1: Discontinue or modify causative medication

   • Discontinue the offending antipsychotic if clinically possible 1, 2
   • If discontinuation not possible, switch to atypical antipsychotic with lower D2 receptor affinity (e.g., clozapine or quetiapine) 1, 2

   Step 2: Consider VMAT2 inhibitors

   • Valbenazine (FDA-approved for TD) 3

     • Dosing: Start at lower doses and titrate as needed
     • Requires dosage adjustment in CYP2D6 poor metabolizers

   • Deutetrabenazine (FDA-approved for TD) 4

     • Starting dose: 12 mg/day
     • Titrate in 6 mg increments weekly
     • Maximum dose: 48 mg/day
     • Demonstrated significant improvement in AIMS scores in clinical trials

Special Considerations

Medication Selection

• VMAT2 inhibitors (valbenazine and deutetrabenazine) have the strongest evidence for efficacy 1, 2
• Anticholinergic medications should be avoided for TD treatment as they may actually worsen symptoms 1
• Beta-blockers may provide limited relief 1
• Benzodiazepines have shown limited efficacy 1

Monitoring

• Use AIMS assessments every 3-6 months to track progress 1
• Careful titration of VMAT2 inhibitors is essential for optimal effect 1

Common Pitfalls to Avoid

1. Misdiagnosis: TD can be confused with akathisia or withdrawal dyskinesia 1
2. Inappropriate use of anticholinergics: These may worsen TD symptoms unless coexisting drug-induced parkinsonism is present 1
3. Abrupt discontinuation of medications can destabilize mood and potentially worsen movement disorders 1
4. Undertreatment: TD can significantly impact quality of life and requires active management 2

High-Risk Populations

• Elderly patients (up to 50% risk after 2 years of typical antipsychotic use) 1
• Children and adolescents (5-20% point prevalence) 5
• Risk factors include: female gender, higher doses, longer duration of exposure, intellectual impairment, and higher baseline AIMS scores 1, 5

Treatment of TD Variants

• Tardive dystonia and tardive akathisia: These variants are typically more severe and difficult to treat than classic TD 6
• For focal tardive dystonia: Consider botulinum toxin injections 7
• For severe, medication-refractory cases: Deep brain stimulation may be considered 7

The management of TD requires careful consideration of the risks and benefits of continuing antipsychotic therapy versus the potential for psychiatric symptom relapse with discontinuation. VMAT2 inhibitors represent a significant advance in TD treatment, offering effective symptom control while allowing continuation of necessary psychiatric medications.