How is tardive dyskinesia managed?

Management of Tardive Dyskinesia

The first-line management of tardive dyskinesia (TD) is discontinuation of the causative dopamine receptor antagonist medication if clinically feasible, followed by switching to an atypical antipsychotic with lower D2 affinity if discontinuation is not possible, and considering VMAT2 inhibitors like deutetrabenazine for persistent symptoms. 1, 2

Diagnostic Assessment

• Use the Abnormal Involuntary Movement Scale (AIMS) for baseline and follow-up assessments
• Assess for dyskinesias at least every 3-6 months during antipsychotic therapy 1
• Document baseline measures of abnormal movements before starting antipsychotic therapy
• Avoid misdiagnosis of TD with akathisia or withdrawal dyskinesia 1

Management Algorithm

Step 1: Prevention

• Limit exposure to dopamine receptor blocking agents (DRBAs) whenever possible
• Use minimum effective doses of antipsychotics
• Document and discuss TD risk with patients before starting DRBAs 3
• Consider regular monitoring with AIMS every 3-6 months 1

Step 2: When TD is Detected

1. Discontinue the causative agent if clinically feasible 1, 2

   • Avoid abrupt cessation as this can worsen symptoms 3
   • Contrary to some beliefs, dose reduction of conventional antipsychotics tends to improve rather than exacerbate TD 4

2. If antipsychotic discontinuation is not possible:

   • Switch to an atypical antipsychotic with lower D2 receptor affinity (clozapine or quetiapine) 1, 2
   • Continue regular monitoring with AIMS assessments 1, 5

3. For persistent TD symptoms:

   • Consider VMAT2 inhibitors (deutetrabenazine, valbenazine) which have the strongest evidence for efficacy 6, 2
   • Deutetrabenazine has demonstrated significant improvement in AIMS total scores compared to placebo (3.3 and 3.2 units reduction for 36mg and 24mg doses, respectively, versus 1.4 units for placebo) 6
   • Start deutetrabenazine at 6mg/day and titrate weekly in 6mg increments to optimal dose (average effective dose ~38mg/day) 6

Step 3: Alternative Pharmacological Options

• Second-line agents with better tolerability profiles:
  • Amantadine
  • Benzodiazepines
  • Beta-blockers
  • Levetiracetam 3
• Consider tocopherol (vitamin E) which is generally well-tolerated 7
• For focal symptoms (e.g., tongue protrusion, blepharospasm), consider botulinum toxin injections 3

Special Considerations

Monitoring During Treatment

• Regular AIMS assessments every 3-6 months
• Monitor for adverse effects of VMAT2 inhibitors, particularly depression, akathisia, and parkinsonism 3
• For patients on deutetrabenazine, titrate dose carefully over 4-6 weeks to minimize side effects 6

Common Pitfalls to Avoid

• Using anticholinergics inappropriately: Anticholinergics do not alleviate TD symptoms and may actually aggravate them 1
• Abrupt discontinuation of antipsychotics: This can worsen TD symptoms and destabilize psychiatric conditions 1, 3
• Misdiagnosis: TD can be confused with akathisia or withdrawal dyskinesia 1
• Delayed intervention: Early detection and management improves prognosis as the risk of permanence increases over time 5

When Antipsychotics Cannot Be Discontinued

• If continuing antipsychotics is necessary for psychiatric stability:
  • Switch to atypical antipsychotics with lower risk (clozapine, quetiapine)
  • Add VMAT2 inhibitors like deutetrabenazine while monitoring for parkinsonism 3
  • As a last resort for disabling symptoms, some advocate resuming treatment with the DRBA to suppress TD symptoms, though this may worsen TD in the long run 3

Patient Education

• Educate patients and caregivers about the risks of antipsychotic medications
• Discuss early signs of TD and the importance of reporting them promptly 5
• Explain that TD may persist even after discontinuation of the causative medication 1