What is the best treatment for Tardive Dyskinesia (TD) caused by antipsychotic use?

Best Treatment for Tardive Dyskinesia Due to Antipsychotic Use

First-Line Treatment

VMAT2 inhibitors (valbenazine or deutetrabenazine) are the first-line treatment for moderate to severe tardive dyskinesia caused by antipsychotic use, as recommended by the American Psychiatric Association. 1

These FDA-approved medications have demonstrated significant efficacy in reducing TD symptoms:

• Valbenazine (Ingrezza):

  • Starting dose: 40 mg daily
  • Target dose: 80 mg once daily
  • Response rates: 33-50% reduction in TD symptoms 1, 2
  • Advantage: Once-daily dosing

• Deutetrabenazine (Austedo):

  • Effective doses: 24-36 mg/day
  • Requires twice-daily administration with food 1, 3

Treatment Algorithm

1. Assess TD severity using the Abnormal Involuntary Movement Scale (AIMS) to establish baseline and monitor treatment response 1, 4

2. Consider medication adjustments:

   • If clinically feasible, attempt to discontinue or reduce the dose of the causative antipsychotic 5, 1
   • If antipsychotic therapy must continue, consider switching from a first-generation to a second-generation antipsychotic with lower D2 affinity (e.g., quetiapine) 1, 6

3. Initiate VMAT2 inhibitor therapy for moderate to severe or disabling TD 1, 4

   • Start with lower doses and titrate gradually to minimize side effects
   • Monitor for clinical response using AIMS at regular intervals

4. For patients who don't respond to or cannot tolerate VMAT2 inhibitors, consider second-line agents:

   • Amantadine
   • Clonazepam (benzodiazepine)
   • Ginkgo biloba
   • Beta-blockers 1, 7

Important Considerations

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

• Special populations:

  • Elderly patients have higher risk (up to 50% after 2 years of typical antipsychotic use) 1
  • CYP2D6 poor metabolizers require dose adjustments for valbenazine 2
  • Patients with hepatic impairment may have contraindications to deutetrabenazine 1

• Regular monitoring is essential:

  • Assess for TD using AIMS every 3-6 months 1
  • Document baseline abnormal movements before starting antipsychotics 1

Prevention Strategies

• Use minimum effective doses of antipsychotics
• Limit duration of antipsychotic therapy when possible
• Prefer second-generation over first-generation antipsychotics
• Avoid anticholinergic medications when possible 1, 4

TD is often irreversible once established, making early intervention with VMAT2 inhibitors crucial for improving quality of life and reducing morbidity in affected patients 4, 8.