What is the treatment for tardive dyskinesia (TD)?

Treatment of Tardive Dyskinesia

The first-line treatment for tardive dyskinesia (TD) includes VMAT2 inhibitors (valbenazine or deutetrabenazine), which have demonstrated significant efficacy in reducing TD symptoms and are FDA-approved specifically for this condition. 1, 2, 3

Prevention and Risk Reduction

• Prevention is critical as treatment options for established TD are limited 4
• Use atypical antipsychotics when possible, as they have lower TD risk compared to typical antipsychotics 4, 5
• Perform baseline assessment of abnormal movements before starting antipsychotic therapy 4
• Monitor regularly for dyskinesias every 3-6 months using standardized measures like the Abnormal Involuntary Movement Scale (AIMS) 4, 5
• Early detection is crucial as TD may persist even after medication discontinuation 4

Management Algorithm for Established TD

First-line approaches:

• If clinically feasible, gradually withdraw the offending antipsychotic medication 4, 5, 6
• For patients requiring continued antipsychotic therapy, consider switching to an atypical antipsychotic with lower D2 affinity, such as clozapine or quetiapine 4, 5, 6
• Initiate VMAT2 inhibitor therapy for moderate to severe TD 1, 2, 3:
  • Valbenazine: FDA-approved with demonstrated efficacy in reducing AIMS scores 2
  • Deutetrabenazine: FDA-approved with significant improvement in Total Maximal Chorea Score 1

Dosing considerations:

• Valbenazine: Typically started at lower doses and titrated as needed 2
• Deutetrabenazine: Initial dose of 12 mg/day with increases in 6 mg increments at weekly intervals until satisfactory control is achieved (maximum 48 mg/day) 1
• Dose adjustments may be needed for CYP2D6 poor metabolizers 2

Monitoring Treatment Response

• Use standardized assessment tools like AIMS to objectively measure TD improvement 1, 2
• Regular follow-up is essential to assess ongoing need for treatment and medication adjustments 4
• Monitor for potential side effects of VMAT2 inhibitors 1, 2

Special Considerations

• Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia 4, 5
• The concern over TD should not outweigh potential benefits of antipsychotics for patients who genuinely need these medications 4, 5
• Adequate informed consent regarding TD risk is necessary when prescribing antipsychotics 4
• For patients with mild TD, reducing the neuroleptic dose may be sufficient 7
• For moderate to severe TD, VMAT2 inhibitors are recommended as the most effective agents 1, 2, 3

Common Pitfalls to Avoid

• Avoid anticholinergic treatments for TD as they can worsen symptoms (important to differentiate TD from drug-induced parkinsonism) 3
• Don't confuse TD with other movement disorders that may require different management approaches 7, 3
• Avoid restarting or increasing antipsychotic doses to mask TD symptoms, as this may worsen the condition long-term 6, 8
• Don't delay treatment of moderate to severe TD, as the risk of permanence increases over time 3