What are the management options for tardive dyskinesia?

Management of Tardive Dyskinesia

The most effective approach to managing tardive dyskinesia is prevention through careful antipsychotic prescribing practices, early detection with regular monitoring, and treatment with FDA-approved VMAT2 inhibitors (valbenazine or deutetrabenazine) when TD develops. 1, 2, 3

Prevention Strategies

• Tardive dyskinesia (TD) is an involuntary movement disorder typically affecting the orofacial region but potentially involving any body part, associated with long-term use of dopamine receptor-blocking agents 1
• Prevention is critical as there are limited specific treatments for TD other than medication discontinuation 1
• Strategies for prevention include:
  • Using atypical antipsychotics when possible, as they have lower TD risk compared to typical antipsychotics 4, 5
  • Limiting antipsychotic use to specific indications with minimum effective doses 6
  • Minimizing duration of antipsychotic therapy when clinically feasible 6

Monitoring and Early Detection

• Baseline assessment of abnormal movements should be recorded before starting antipsychotic therapy 1
• Regular monitoring for dyskinesias should occur at least every 3-6 months using standardized measures like the Abnormal Involuntary Movement Scale (AIMS) 1, 4
• The AIMS evaluates severity of involuntary movements across body regions on a scale of 0-4, with total scores ranging from 0-28 2, 3
• Early detection is crucial as TD may persist even after medication discontinuation 1, 4

Management Algorithm for Established TD

First-Line Approaches:

1. Medication Adjustment:

   • If clinically feasible, gradually withdraw the offending antipsychotic medication 1, 6
   • If the patient is in full remission and medication change risks relapse, continue at current dose 1
   • Otherwise, attempt to lower the dose or switch to another medication, preferably an atypical antipsychotic 1, 7
   • Consider switching to atypical antipsychotics with lower D2 affinity (e.g., clozapine or quetiapine) 6

2. FDA-Approved VMAT2 Inhibitors:

   • Deutetrabenazine (AUSTEDO) - demonstrated significant improvement in AIMS total scores in clinical trials 2
   • Valbenazine (INGREZZA) - also showed significant reduction in AIMS dyskinesia total scores 3
   • These medications deplete presynaptic dopamine and reduce involuntary movements 5
   • Dosing should be individualized based on clinical response and tolerability 2, 3
   • Consider CYP2D6 metabolizer status when dosing, particularly for poor metabolizers who may require dose reduction 3

Alternative Options:

• Amantadine - may provide modest benefit in some patients 5, 8
• Clonazepam - can be useful for short-term management 5, 8
• Ginkgo biloba - has shown some benefit in limited studies 5
• Botulinum toxin - particularly effective for focal dystonia 5, 8

Special Considerations

• Withdrawal dyskinesia may occur with gradual or sudden cessation of neuroleptics but almost always resolves over time 1
• True TD may persist even after medication discontinuation 1
• Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia 1
• The concern over TD should not outweigh potential benefits of antipsychotics for patients who genuinely need these medications 1, 9
• Adequate informed consent regarding TD risk is necessary when prescribing antipsychotics 1, 9

Monitoring Treatment Response

• Use the AIMS to objectively assess treatment response 2, 3
• Evaluate for side effects of VMAT2 inhibitors, which may include somnolence, anticholinergic effects, and potential QT prolongation 5
• Regular follow-up is essential to assess ongoing need for treatment and medication adjustments 1