Is benztropine (anticholinergic) effective in treating tardive dyskinesia symptoms?

Benztropine Is Not Effective for Tardive Dyskinesia and May Worsen Symptoms

Benztropine should not be used for tardive dyskinesia as it does not alleviate symptoms and may actually aggravate them. 1, 2 The FDA label specifically states that benztropine is not recommended for use in patients with tardive dyskinesia 2.

Evidence Against Using Benztropine for TD

• The FDA-approved drug label for benztropine explicitly states: "Benztropine mesylate is not recommended for use in patients with tardive dyskinesia" 2
• Guidelines from the American Academy of Family Physicians specifically recommend avoiding benztropine (Cogentin) for TD 1
• Anticholinergic medications like benztropine have a limited and potentially problematic role in TD management, as they may actually worsen symptoms 1
• The drug label warns that "antiparkinsonism agents do not alleviate the symptoms of tardive dyskinesia, and in some instances may aggravate them" 2

Appropriate Management of Tardive Dyskinesia

The management algorithm for TD should follow these steps:

1. Discontinue the causative antipsychotic if clinically feasible 1, 3
2. If discontinuation is not possible, switch to an atypical antipsychotic with lower D2 affinity (such as clozapine or quetiapine) 1, 3
3. Consider VMAT2 inhibitors such as deutetrabenazine or valbenazine, which have the strongest evidence for TD treatment 1, 3
   • Deutetrabenazine at doses of 24-36 mg/day has shown significant reduction in TD symptoms 1
   • Tetrabenazine has demonstrated improvements in AIMS scores for refractory TD at a mean dose of 57.9 mg/day 1, 4

When Anticholinergics May Be Used (Not for TD)

Benztropine is indicated for:

• Treatment of all forms of parkinsonism
• Control of extrapyramidal disorders due to neuroleptic drugs (except tardive dyskinesia) 2

Anticholinergics like benztropine may be appropriate for:

• Acute dystonia
• Drug-induced parkinsonism (benztropine 1-2 mg daily, max 6 mg) 1
• When TD coexists with drug-induced parkinsonism, anticholinergics may be used to treat the parkinsonism symptoms only, not the TD 1

Monitoring and Prevention

• Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months is recommended for patients on antipsychotic therapy 5, 1
• Record baseline measures of abnormal movements before starting antipsychotic therapy 5, 1
• Prevention is crucial since there is no specific treatment for TD other than discontinuing the medication 5

Common Pitfalls to Avoid

1. Misdiagnosis: TD may be confused with akathisia or withdrawal dyskinesia 1
2. Inappropriate use of anticholinergics: Real-world data shows benztropine is often used long-term in TD despite guidelines against this practice 6
3. Lack of guideline awareness: Less than 40% of providers indicated familiarity with current practice guidelines for TD management 6
4. Failure to monitor: Regular assessment for dyskinesias should occur at least every 3-6 months in patients on antipsychotic therapy 5, 1

In conclusion, benztropine should be avoided in tardive dyskinesia management. For patients requiring treatment for TD, VMAT2 inhibitors represent the most evidence-based approach when discontinuation of the causative agent is not possible.