What is the recommended treatment for tardive dyskinesia?

Tardive Dyskinesia Treatment

VMAT2 inhibitors (valbenazine or deutetrabenazine) are the first-line pharmacological treatment for tardive dyskinesia when discontinuation of the causative medication is not feasible. 1

Management Algorithm

1. Prevention and Risk Assessment

   • Regularly assess for dyskinesias every 3-6 months during antipsychotic therapy using the Abnormal Involuntary Movement Scale (AIMS) 1
   • Record baseline measures before starting antipsychotic therapy
   • Use minimum effective doses of antipsychotics for the shortest duration necessary

2. First-Line Approach

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

3. Pharmacological Treatment

   • VMAT2 inhibitors are the most effective pharmacological interventions:
     • Valbenazine: Once-daily dosing (40-80 mg/day), with demonstrated efficacy in reducing AIMS scores by 3.2-3.3 points compared to placebo 3, 4
     • Deutetrabenazine: Twice-daily dosing (24-48 mg/day), with proven efficacy in tardive dyskinesia 5, 6
     • Both medications require careful titration for optimal effect 1
     • For valbenazine, dosage reduction is recommended in CYP2D6 poor metabolizers 3

4. Alternative Treatments (if VMAT2 inhibitors are unavailable or ineffective)

   • Beta-blockers may provide limited relief 1
   • Benzodiazepines have shown limited efficacy 1
   • Electroconvulsive therapy (ECT) should be considered only for severe cases where medications are ineffective 1

Important Considerations and Pitfalls

1. Avoid Anticholinergics for TD

   • Anticholinergic medications do not alleviate TD symptoms and may actually aggravate them 1
   • Only use anticholinergics when TD coexists with drug-induced parkinsonism, not for TD itself 1

2. Monitoring Requirements

   • Continue regular AIMS assessments every 3-6 months 1
   • Monitor for psychiatric stability, as medication changes may affect underlying mental health conditions 1, 7

3. Medication-Specific Considerations

   • Valbenazine: Long-term studies show sustained TD improvement with generally favorable safety and tolerability 7
   • Deutetrabenazine: Shows continued efficacy and good tolerability even when combined with baseline dopamine receptor blocking agents 6
   • Both medications have demonstrated return of TD symptoms after discontinuation, indicating need for continued treatment 3, 5

4. Diagnostic Accuracy

   • Avoid misdiagnosis of TD with akathisia or withdrawal dyskinesia 1
   • Akathisia is often incorrectly diagnosed as psychotic agitation or anxiety 1
   • Withdrawal dyskinesia typically resolves over time, unlike true TD 1

The evidence strongly supports VMAT2 inhibitors as the most effective pharmacological treatment for tardive dyskinesia when discontinuation of the causative medication is not possible. Both valbenazine and deutetrabenazine have demonstrated significant efficacy with favorable safety profiles in clinical trials.