How are tardive dyskinesia symptoms managed?

Management of Tardive Dyskinesia Symptoms

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

Initial Management Steps

1. Prevention and Risk Assessment

   • Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months for patients on antipsychotic therapy 1
   • Record baseline measures before starting antipsychotic therapy
   • Higher risk groups include: elderly patients (up to 50% risk after 2 years of typical antipsychotic use), females, patients with intellectual impairment, and children/adolescents (5-20% prevalence) 1, 2

2. First-line Approach

   • Discontinue the causative antipsychotic if clinically feasible 1, 3
   • Note: Contrary to some clinical beliefs, dose reduction of conventional antipsychotics typically improves rather than worsens TD symptoms 4

3. When Antipsychotic Discontinuation Is Not Possible

   • Switch to an atypical antipsychotic with lower D2 affinity (clozapine or quetiapine) 1, 3
   • Be aware that clozapine may temporarily suppress TD symptoms rather than permanently resolve them 5

Pharmacological Treatment Options

VMAT2 Inhibitors (First-line pharmacological treatment)

1. Valbenazine

   • FDA-approved for TD treatment
   • Dosing considerations:
     • Starting dose: 40 mg once daily
     • Can increase to 80 mg once daily
     • Requires dose adjustment in CYP2D6 poor metabolizers (approximately 7% of White populations, 2% of Asian and African-American populations) 6
   • Demonstrated significant improvement in AIMS total scores compared to placebo 6

2. Deutetrabenazine

   • FDA-approved for TD treatment
   • Demonstrated statistically significant improvement in AIMS total scores (3.3 and 3.2 units reduction for 36 mg and 24 mg arms, respectively, compared to 1.4 units with placebo) 7
   • Typically titrated from 12 mg/day with increases in 6 mg increments at weekly intervals 7

Medications to Avoid

• Anticholinergics (benztropine, trihexyphenidyl) should be avoided for TD treatment as they may actually aggravate symptoms 1
• Only consider anticholinergics when TD coexists with drug-induced parkinsonism, and then only for treating the parkinsonism symptoms, not TD itself 1

Special Considerations

1. Misdiagnosis Pitfalls

   • TD must be differentiated from akathisia (often misdiagnosed as psychotic agitation or anxiety)
   • Withdrawal dyskinesia (occurs with gradual or sudden cessation of neuroleptics and typically resolves over time, unlike true TD) 1

2. Treatment of Coexisting Conditions

   • For acute dystonia: anticholinergics or antihistamines
   • For drug-induced parkinsonism: anticholinergics (benztropine 1-2 mg daily, max 6 mg) or amantadine
   • For akathisia: beta-blockers (propranolol, metoprolol) as first-line; benzodiazepines may provide relief 1

3. Monitoring After Treatment

   • After discontinuation of VMAT2 inhibitors, TD symptoms may return to baseline levels 6, 7
   • Continue regular AIMS assessments even after treatment initiation

Treatment Algorithm

1. Attempt discontinuation of causative antipsychotic if clinically feasible
2. If discontinuation not possible, switch to atypical antipsychotic with lower D2 affinity
3. If TD symptoms persist, initiate VMAT2 inhibitor (valbenazine or deutetrabenazine)
4. For severe cases unresponsive to medication, consider electroconvulsive therapy (particularly in bipolar disorder) 1

By following this evidence-based approach and prioritizing prevention through careful antipsychotic prescribing practices, clinicians can effectively manage tardive dyskinesia symptoms and minimize their impact on patients' quality of life.