From the FDA Drug Label
1 INDICATIONS AND USAGE INGREZZA and INGREZZA SPRINKLE are indicated for the treatment of adults with:
- tardive dyskinesia [see Clinical Studies (14. 1)].
The medication given for tardive dyskinesia is valbenazine (PO), however, the provided drug labels do not specify administration in an Emergency Room (ER) setting. 1
From the Research
In the emergency room, benzodiazepines such as lorazepam (Ativan) 1-2 mg IV or diazepam (Valium) 5-10 mg IV are typically given for acute management of tardive dyskinesia, as they provide rapid symptomatic relief by enhancing the effect of the inhibitory neurotransmitter GABA in the brain 2.
Key Considerations
- The primary goal in the ER setting is to manage symptoms temporarily while arranging for follow-up care, as the underlying cause of tardive dyskinesia, often related to antipsychotic medication, needs to be addressed under psychiatric supervision.
- For longer-term management, vesicular monoamine transporter 2 (VMAT2) inhibitors like valbenazine (Ingrezza) or deutetrabenazine (Austedo) are preferred, but these are not typically initiated in the ER setting due to their specific indications and the need for careful patient selection and monitoring 3, 4.
- Anticholinergic medications, sometimes used for acute dystonic reactions, are generally avoided in tardive dyskinesia as they may worsen symptoms over time.
Evidence Summary
- A study from 2020 discusses the management of tardive syndrome, including the use of VMAT2 inhibitors as first-choice agents due to their level A evidence and FDA approval for this purpose 3.
- The 2018 Cochrane review on benzodiazepines for antipsychotic-induced tardive dyskinesia found very low-quality evidence, suggesting that while benzodiazepines may provide some benefit, their use is not clearly indicated due to their addictive potential and the lack of high-quality evidence 2.
- More recent guidance from 2022 emphasizes the effectiveness of VMAT2 inhibitors and suggests other drugs like clonazepam, amantadine, and Ginkgo biloba extract may be effective in some patients, with botulinum toxin and deep brain stimulation as potential options for refractory cases 4.
Clinical Decision
Given the need for rapid symptom management in the ER and the potential for benzodiazepines to provide temporary relief, their use is justified in this context, despite the limitations in evidence quality and the preference for VMAT2 inhibitors in long-term management. It is crucial to prioritize arrangements for follow-up care to address the underlying cause of tardive dyskinesia.