What is the management for Tardive Dyskinesia (TD)?

Management of Tardive Dyskinesia

The first-line management for tardive dyskinesia (TD) is prevention and, when TD develops, the gradual withdrawal of the offending dopamine receptor-blocking agent if clinically feasible. 1, 2

Prevention and Early Detection

• 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 strategies include:
  • Using atypical antipsychotics when possible, as they have lower TD risk compared to typical antipsychotics 1, 2
  • Using the lowest effective dose of antipsychotics 1
  • Minimizing duration of therapy with dopamine receptor-blocking agents 1
• Baseline assessment of abnormal movements should be recorded before starting antipsychotic therapy 1, 2
• Regular monitoring for dyskinesias should occur at least every 3-6 months using standardized measures like the Abnormal Involuntary Movement Scale (AIMS) 1, 2
• Early detection is crucial as TD may persist even after medication discontinuation 1

Management Algorithm for Established TD

Step 1: Medication Adjustment

• If clinically feasible, gradually withdraw the offending antipsychotic medication 1, 2
• Abrupt cessation should be avoided as this can worsen symptoms 3
• For patients requiring continued antipsychotic treatment, consider switching to atypical antipsychotics with lower D2 affinity, such as clozapine or quetiapine 1, 2, 4

Step 2: Pharmacological Treatment

• For moderate to severe or disabling TD, VMAT2 inhibitors are FDA-approved and recommended treatments 5, 6, 7
  • Deutetrabenazine (AUSTEDO) has demonstrated statistically significant improvement in AIMS total scores compared to placebo in clinical trials 5
  • Valbenazine (INGREZZA) has also shown significant improvement in AIMS dyskinesia total scores 6
• Second-line agents with better tolerability profiles that may be considered include:
  • Amantadine
  • Benzodiazepines
  • Beta-blockers
  • Levetiracetam 3

Step 3: Management of Focal Symptoms

• For focal symptoms such as tongue protrusion or blepharospasm, botulinum toxin injections can be effective 3

Monitoring Treatment Response

• Regular follow-up is essential to assess ongoing need for treatment and medication adjustments 1
• The AIMS examination should be used to monitor TD, especially when providing treatments intended to decrease symptoms 7

Special Considerations

• Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia 1, 2
• The concern over TD should not outweigh potential benefits of antipsychotics for patients who genuinely need these medications 1, 2
• Adequate informed consent regarding TD risk is necessary when prescribing antipsychotics 1
• Dose reduction of conventional antipsychotics tends to improve rather than exacerbate TD, contrary to some clinical beliefs 8
• For patients with tardive dystonia, anticholinergic agents may be particularly effective 9

Pitfalls and Caveats

• Clinicians should differentiate between TD and other drug-induced movement disorders, particularly drug-induced parkinsonism, as anticholinergic treatment can worsen TD 7
• As a last resort, when disabling, life-threatening symptoms of TD persist despite other treatments, some advocate resuming treatment with the dopamine receptor-blocking agent to suppress symptoms of TD, though this has potential to worsen TD in the long run 3
• Tetrabenazine, while effective, may cause adverse effects such as depression, akathisia, and parkinsonism that require monitoring 3