What are the treatment options for tardive dyskinesia?

Treatment Options for Tardive Dyskinesia

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

Management Algorithm

1. Prevention and Early Detection

   • Regular monitoring using the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months for patients on antipsychotic therapy 1
   • Record baseline measures of abnormal movements before starting antipsychotic therapy 1

2. First-line Approach

   • Discontinue the causative antipsychotic if clinically feasible 1
   • If discontinuation is not possible, switch to an atypical antipsychotic with lower D2 affinity (e.g., clozapine or quetiapine) 1

3. Pharmacological Treatment with VMAT2 Inhibitors

   • Valbenazine:

     • FDA-approved for TD treatment 2
     • Once-daily dosing (advantage over older treatments) 3
     • Demonstrated significant reduction in AIMS scores compared to placebo (-3.2 vs -0.1) 4
     • Rapid onset of effect within 2 weeks 3

   • Deutetrabenazine:

     • FDA-approved for TD treatment 5
     • Doses of 24 mg/day and 36 mg/day have shown significant reduction in TD symptoms 1
     • Demonstrated statistically significant improvement in AIMS total score compared to placebo 5

4. Other Treatment Options

   • Electroconvulsive therapy (ECT) for severe cases where medications are ineffective or not tolerated, particularly in bipolar disorder 1
   • Beta-blockers may provide some relief, although evidence is limited 1
   • Benzodiazepines have shown limited efficacy 1

Important Considerations and Cautions

• Avoid anticholinergics for TD treatment:

  • Medications like benztropine (Cogentin) or trihexyphenidyl (Artane) should NOT be used for TD 1
  • Anticholinergics do not alleviate TD symptoms and may actually aggravate them 1
  • Only appropriate for coexisting drug-induced parkinsonism, not for TD itself 1

• Special populations:

  • For valbenazine, dosage reduction is recommended in CYP2D6 poor metabolizers 2
  • Elderly patients are at increased risk for developing TD (up to 50% after 2 years of continuous typical antipsychotic use) 1
  • Children and adolescents have a point prevalence of 5-20% for TD 1

• Monitoring during treatment:

  • Continue regular AIMS assessments to track treatment response
  • Watch for potential adverse effects of VMAT2 inhibitors
  • Be aware that TD symptoms typically return after discontinuation of VMAT2 inhibitors 2, 5

Common Pitfalls to Avoid

• Misdiagnosing TD with akathisia or withdrawal dyskinesia 1
• Inappropriate long-term use of anticholinergics for TD management 1
• Failing to recognize that TD may persist even after discontinuation of the causative medication 1
• Not considering switching to lower-risk antipsychotics when discontinuation is not possible 1

By following this evidence-based approach to TD management, clinicians can effectively address this challenging movement disorder while minimizing risks and optimizing outcomes for patients.