From the FDA Drug Label
5.18 Tardive Dyskinesia Tardive dyskinesia (TD) has occurred in patients treated with antipsychotic drugs, including clozapine. The FDA drug label does not answer the question.
From the Research
Clozapine is the antipsychotic of choice for patients with tardive dyskinesia, as it has the lowest risk of causing or worsening tardive dyskinesia among all antipsychotics. When a patient develops tardive dyskinesia while on a typical or atypical antipsychotic, switching to clozapine is recommended, as supported by the most recent study 1. The typical starting dose is 12.5 mg once or twice daily, gradually titrated upward to an effective dose (usually 300-450 mg/day), divided into two doses. Clozapine requires regular blood monitoring due to the risk of agranulocytosis, with weekly complete blood counts for the first 6 months, then every 2 weeks for 6 months, and monthly thereafter if counts remain stable.
Key Considerations
- The effectiveness of clozapine in tardive dyskinesia is attributed to its unique receptor binding profile, with lower D2 receptor occupancy and higher affinity for D1, D4, and serotonergic receptors compared to other antipsychotics 2.
- If clozapine cannot be used, quetiapine or olanzapine may be considered as alternatives with relatively lower risk of exacerbating tardive dyskinesia, though they are not as effective as clozapine for this specific indication 3, 4.
- Other treatment options, such as deutetrabenazine and modified electroconvulsive therapy (MECT), may also be considered in conjunction with clozapine for patients with severe tardive dyskinesia 1.
Treatment Approach
- Preventing tardive dyskinesia is of primary importance, and clinicians should follow best practice for prescribing antipsychotic medication, including limiting the prescription for specific indications, using the minimum effective dose, and minimizing the duration of therapy 2.
- For patients with existing tardive dyskinesia, a comprehensive treatment approach may involve switching to clozapine, adjunctive therapy with deutetrabenazine, and/or MECT, as well as regular monitoring and adjustment of treatment as needed 1.