What are the next steps for a patient taking Wellbutrin (bupropion) 300 mg extended release, Lamictal (lamotrigine) 250 mg extended release, propanolol (propranolol) 10 mg, Prozac (fluoxetine) 20 mg, and Abilify (aripiprazole) 10 mg, who is currently stable but experiencing symptoms of tardive dyskinesia, including lip smacking, restlessness in the legs, and tongue smacking or protrusion?

Management of Tardive Dyskinesia in a Patient on Multiple Psychotropic Medications

For a patient experiencing tardive dyskinesia symptoms while on Abilify (aripiprazole), the most appropriate next step is to consider switching from aripiprazole to a different atypical antipsychotic with lower risk of tardive dyskinesia, such as quetiapine, or adding a VMAT2 inhibitor. 1, 2

Diagnosis Confirmation

The patient's symptoms strongly suggest tardive dyskinesia (TD):

• Orofacial movements (lip smacking, tongue protrusion)
• Restlessness in the legs
• Current regimen includes aripiprazole 10mg, which is associated with TD risk

Management Algorithm

Step 1: Medication Adjustment

• Option A: Modify current antipsychotic

  • Consider switching from aripiprazole to quetiapine (initial dose: 12.5mg twice daily; maximum: 200mg twice daily) 3
  • Aripiprazole, despite being an atypical antipsychotic, can cause TD as evidenced by case reports 4
  • FDA labeling for aripiprazole specifically warns about TD risk 2

• Option B: Optimize beta-blocker therapy

  • Current propranolol dose (10mg) may be insufficient
  • Increase propranolol to 10-30mg two to three times daily 3
  • Monitor for cardiovascular effects, especially with concurrent fluoxetine

Step 2: If TD persists after medication adjustment

• Consider adding a VMAT2 inhibitor (valbenazine or deutetrabenazine) 3, 5
• These medications are specifically approved for TD treatment
• May be used while continuing psychiatric medications if they're necessary for stability

Medication Interactions and Considerations

The patient is on a complex regimen that requires careful consideration:

• Bupropion (Wellbutrin) 300mg XR
• Lamotrigine (Lamictal) 250mg XR
• Propranolol 10mg
• Fluoxetine (Prozac) 20mg
• Aripiprazole (Abilify) 10mg

Important considerations:

1. The combination of multiple psychotropics increases TD risk 1
2. Propranolol at current dose may be insufficient for TD/akathisia management 3
3. Fluoxetine can increase aripiprazole levels through CYP2D6 inhibition, potentially worsening TD

Monitoring Recommendations

• Use the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months to track TD progression 1
• Monitor for metabolic effects if switching to quetiapine (blood glucose, lipids, weight) 2
• If propranolol dose is increased, monitor for hypotension, bradycardia, and bronchospasm 3

Important Cautions

• Avoid anticholinergic agents (like benztropine) as they can worsen TD while potentially helping drug-induced parkinsonism 5
• TD may persist even after discontinuing the causative agent 6
• Abrupt withdrawal of antipsychotics can worsen TD symptoms; any changes should be gradual 1, 2
• Some patients may require continued antipsychotic treatment despite TD if psychiatric stability is at risk 2

Prognosis

TD can be persistent and may not fully resolve even with appropriate interventions. Early detection and management are crucial to prevent irreversible symptoms 1, 7. While some cases of TD may improve with medication changes, the patient should be informed that symptoms might persist despite treatment.