How to manage significant stuttering and shaking in a patient with Tardive Dyskinesia (TD) on deutetrabenazine (VMAT2 inhibitor) 8 mg daily?

Management of Tardive Dyskinesia with Significant Stuttering and Shaking

For a patient with tardive dyskinesia experiencing significant stuttering and shaking on deutetrabenazine 8 mg daily, the most effective approach is to increase the deutetrabenazine dose to 24-36 mg daily, as higher doses have demonstrated statistically significant improvement in TD symptoms compared to lower doses.

Optimizing VMAT2 Inhibitor Therapy

• The current dose of deutetrabenazine (8 mg daily) is significantly below the therapeutic range shown to be effective in clinical trials, where doses of 24-36 mg daily demonstrated statistically significant improvement in TD symptoms 1
• Deutetrabenazine should be titrated gradually, with increases of 6 mg/day at weekly intervals until optimal symptom control is achieved, with a maximum recommended dose of 48 mg/day (24 mg twice daily) 1
• In clinical trials, deutetrabenazine 24 mg and 36 mg daily provided significant reduction in TD symptoms with favorable safety and tolerability profiles, with AIMS score improvements of 3.2 and 3.3 points respectively, compared to only 1.4 points with placebo 2
• The average effective dose in flexible-dose trials was 38.3 mg daily, suggesting that many patients require higher doses for optimal symptom control 1

Speech-Specific Interventions for Stuttering

• For stuttering symptoms specifically, implement techniques to reduce excessive musculoskeletal tension in speech and non-speech muscles 3:

  • Reduce muscle tension in head, neck, shoulders with targeted relaxation techniques 3
  • Palpate or manipulate facial muscles to reduce tension 3
  • Implement speech restructuring techniques including slowing speech rate and using easy, gentle onset 3

• Consider distraction techniques that can be gradually faded as speech normalizes 3:

  • Speaking while squeezing a ball 3
  • Finger tapping while speaking 3
  • Dual tasking while speaking as a form of distraction 3

Additional Pharmacological Options

• If deutetrabenazine dose optimization does not provide adequate relief, consider these alternatives:
  • Valbenazine (another VMAT2 inhibitor) may be considered as an alternative if deutetrabenazine is not tolerated or ineffective 4
  • If clinically feasible and psychiatric stability permits, consider gradually withdrawing the original offending dopamine receptor-blocking agent that caused the TD 5
  • For patients who cannot tolerate oral medications due to severe orofacial symptoms, crushed deutetrabenazine administered via feeding tube has shown benefit in case reports 6

Monitoring Treatment Response

• Use standardized measures like the Abnormal Involuntary Movement Scale (AIMS) at baseline and then every 3-6 months to objectively track symptom progression and treatment response 4, 5
• Regular assessment of both stuttering and involuntary movements is crucial for dose adjustments and determining treatment efficacy 4
• In clinical trials, physicians rated 42% of patients treated with deutetrabenazine as "Much Improved" or "Very Much Improved" at the end of treatment compared to only 13% of placebo-treated patients 1

Pitfalls and Special Considerations

• Underdosing is a common pitfall in TD management - the current 8 mg daily dose is significantly below the therapeutic range shown in clinical trials (24-48 mg daily) 1, 2
• Deutetrabenazine should be administered with food to maximize absorption 1
• The most common adverse events with deutetrabenazine are nasopharyngitis and insomnia, which occur at relatively low rates compared to placebo 7, 8
• Discontinuation rates due to adverse events are similar between deutetrabenazine and placebo (3.6% vs 3.1%), indicating good tolerability even at higher doses 7

Treatment Algorithm

1. Increase deutetrabenazine dose gradually by 6 mg/week to target 24-36 mg daily (divided twice daily) 1, 2
2. Implement speech therapy techniques focused on reducing muscle tension and speech restructuring 3
3. Monitor response using standardized measures (AIMS) every 3-6 months 4
4. If inadequate response after reaching maximum tolerated dose (up to 48 mg daily), consider alternative VMAT2 inhibitor or adjunctive therapy 4, 5
5. Continue regular monitoring even after symptom improvement to assess for potential worsening or recurrence 5