What is the treatment for tardive dyskinesia?

Treatment for Tardive Dyskinesia

Patients with moderate to severe or disabling tardive dyskinesia should be treated with a vesicular monoamine transporter 2 (VMAT2) inhibitor such as valbenazine or deutetrabenazine, as recommended by the American Psychiatric Association. 1

First-Line Management Approach

1. Prevention is primary

   • Use antipsychotics only when clinically indicated
   • Prescribe minimum effective doses
   • Monitor regularly using AIMS every 3-6 months
   • Record baseline abnormal movements before starting antipsychotics 1

2. When TD is diagnosed:

   • Consider discontinuation of the causative antipsychotic if clinically feasible 1, 2
   • If discontinuation is not possible due to risk of psychiatric relapse, consider switching to a second-generation antipsychotic with lower D2 affinity (e.g., clozapine or quetiapine) 2

3. VMAT2 inhibitors as first-line pharmacological treatment:

   • Valbenazine (Ingrezza):

     • Starting dose: 40 mg once daily
     • Target dose: 80 mg once daily
     • Advantages: Once-daily dosing, rapid onset within 2 weeks 1, 3

   • Deutetrabenazine (Austedo):

     • Effective doses: 24-36 mg/day
     • Administration: Twice daily with food
     • Requires gradual titration to minimize side effects 1, 4

Efficacy and Response Rates

• Both VMAT2 inhibitors demonstrate significant reduction in TD symptoms as measured by the AIMS
• Response rates range from 33% to 50% 1
• In clinical trials, valbenazine showed statistically significant improvement in AIMS scores compared to placebo 3
• Deutetrabenazine demonstrated similar efficacy in reducing TD symptoms 4

Special Considerations and Monitoring

1. Risk factors requiring closer monitoring:

   • Elderly patients (up to 50% risk after 2 years of continuous typical antipsychotic use)
   • Female gender
   • Higher baseline AIMS scores
   • Intellectual impairment 1

2. Medication adjustments:

   • For CYP2D6 poor metabolizers: Reduce valbenazine dosage 3
   • For patients with hepatic impairment: Deutetrabenazine may be contraindicated 1
   • Monitor for depression and suicidal ideation, particularly in patients with Huntington's disease 1

3. Medications to avoid:

   • Anticholinergics (benztropine, trihexyphenidyl) as they may worsen TD symptoms 1

Alternative Treatments (When VMAT2 inhibitors are unavailable or not tolerated)

• Amantadine
• Clonazepam
• Ginkgo biloba
• Beta-blockers
• Electroconvulsive therapy (ECT) for severe cases unresponsive to medication 1

Differential Diagnosis

It is crucial to differentiate TD from other movement disorders:

• Drug-induced parkinsonism
• Akathisia
• Withdrawal dyskinesia

Misdiagnosis can lead to inappropriate treatment that may worsen TD symptoms 1

Follow-up and Monitoring

• Use AIMS for baseline assessment and regular follow-up evaluations
• Monitor for symptom improvement using standardized scales
• Assess for side effects of VMAT2 inhibitors
• Continue regular monitoring even after symptom improvement 1, 5

Remember that early diagnosis and intervention are critical, as the risk of permanent TD increases with time. The goal of treatment is to reduce the severity of involuntary movements and improve quality of life while maintaining effective control of the underlying psychiatric condition.