What is the recommended treatment for tardive dyskinesia?

Treatment of Tardive Dyskinesia

The first-line treatment for tardive dyskinesia is VMAT2 inhibitors (valbenazine or deutetrabenazine), which have demonstrated significant efficacy in reducing involuntary movements with favorable safety profiles. 1

Management Algorithm

1. Prevention and Risk Reduction

   • Use antipsychotics only when clinically indicated
   • Use lowest effective dose of antipsychotics
   • Regularly monitor for early signs of TD using AIMS assessment (every 3-6 months)
   • Consider baseline AIMS assessment before starting antipsychotics

2. When TD is Diagnosed

   • Step 1: Discontinue the causative antipsychotic if clinically feasible
   • Step 2: If discontinuation not possible, switch to an atypical antipsychotic with lower D2 affinity (e.g., clozapine or quetiapine)
   • Step 3: Initiate VMAT2 inhibitor therapy

3. VMAT2 Inhibitor Options

   • Valbenazine (INGREZZA)

     • Starting dose: 40 mg once daily
     • Can increase to 80 mg once daily
     • Dosage reduction recommended in CYP2D6 poor metabolizers 2
     • Demonstrated significant improvement in AIMS scores (-3.2 for 80 mg/day vs -0.1 for placebo) 3

   • Deutetrabenazine (AUSTEDO)

     • Starting dose: 12 mg/day
     • Titrate weekly in 6 mg increments to optimal dose (typically 24-48 mg/day)
     • Administered in divided doses twice daily 4
     • Demonstrated significant improvement in AIMS scores in clinical trials 5

Special Considerations

Medication Selection

• Both valbenazine and deutetrabenazine are effective for TD
• Valbenazine offers once-daily dosing advantage 6
• Deutetrabenazine requires twice-daily dosing but may have fewer side effects than older tetrabenazine formulations 5

Monitoring

• Regular AIMS assessments (every 3-6 months) to evaluate treatment response
• Monitor for potential adverse effects:
  • Valbenazine: nasopharyngitis, somnolence
  • Deutetrabenazine: somnolence, insomnia

Important Caveats

• Avoid anticholinergic medications for TD treatment as they may actually worsen symptoms 1
• Beta-blockers and benzodiazepines have limited efficacy for TD 1
• Electroconvulsive therapy (ECT) should be considered only for severe cases where medications are ineffective 1
• Be careful not to misdiagnose TD with akathisia or withdrawal dyskinesia 1

Efficacy Evidence

• VMAT2 inhibitors have demonstrated sustained improvement in TD symptoms over long-term treatment (up to 48 weeks) 7
• After discontinuation of VMAT2 inhibitors, TD symptoms typically return toward baseline levels, indicating the need for continued treatment 7
• In clinical trials, 51% of patients treated with valbenazine rated their symptoms as "Much Improved" or "Very Much Improved" compared to 20% of placebo-treated patients 2

VMAT2 inhibitors represent a significant advance in TD management, providing effective symptom control while maintaining psychiatric stability in patients who require ongoing antipsychotic treatment.