What is the treatment for drug-induced dyskinesia?

Treatment of Drug-Induced Dyskinesia

The primary treatment for drug-induced dyskinesia is to discontinue or reduce the dose of the offending medication, with atypical antipsychotics being the preferred alternative if continued antipsychotic treatment is necessary. 1

Types of Drug-Induced Dyskinesia

• Drug-induced dyskinesia encompasses involuntary movement disorders that typically occur after exposure to dopamine receptor-blocking agents (DRBAs), including antipsychotics 2
• The most common forms include:
  • Tardive dyskinesia (TD): characterized by athetoid or choreic movements, typically in the orofacial region 1
  • Tardive dystonia: characterized by slow movements along the body's long axis culminating in spasms 1
  • Acute dystonia: sudden spastic contractions of distinct muscle groups 1
  • Drug-induced parkinsonism: bradykinesia, rigidity, and tremor 3
  • Akathisia: severe restlessness manifesting as pacing or physical agitation 1

First-Line Management Approaches

For Drug-Induced Tardive Dyskinesia

1. Discontinue the offending medication if clinically feasible 1, 4

   • For drug-induced RBD specifically, drug discontinuation is strongly recommended 1
   • Withdrawal dyskinesias may occur but typically resolve over time, unlike persistent TD 1

2. If antipsychotic therapy must continue:

   • Switch to an atypical antipsychotic with lower TD risk 4, 5
   • Consider dose reduction of the current medication 1
   • Atypical antipsychotics (e.g., risperidone, olanzapine, quetiapine) have lower risk of causing extrapyramidal symptoms and TD compared to typical antipsychotics 1

For Acute Extrapyramidal Symptoms

• Acute dystonia: Treat with anticholinergic medications (e.g., benztropine) or antihistamines 1
• Drug-induced parkinsonism: Use anticholinergic agents or amantadine 1, 3
• Akathisia: Lower the antipsychotic dose if possible; consider β-blockers or benzodiazepines 1

Second-Line Treatment Options

• VMAT2 inhibitors: These are now considered the treatment of choice for persistent TD 2

  • Deutetrabenazine and valbenazine are FDA-approved specifically for TD 2
  • These medications deplete presynaptic dopamine and reduce involuntary movements 2

• Other pharmacological options:

  • Amantadine: May help with TD and has the advantage of not worsening comorbid drug-induced parkinsonism 3
  • Clonazepam: May provide relief for some patients with TD 2
  • Ginkgo biloba: Has shown some efficacy in TD management 2

• For focal dystonia or tardive dystonia:

  • Botulinum toxin injections may be helpful 6

• For severe, refractory cases:

  • Deep brain stimulation may be considered when other treatments fail 6

Prevention Strategies

• Use atypical antipsychotics when possible, as they have lower TD risk compared to typical antipsychotics 4
• Perform baseline assessment of abnormal movements before starting antipsychotic therapy 4
• Monitor regularly for dyskinesias at least every 3-6 months using the Abnormal Involuntary Movement Scale (AIMS) 4
• Provide adequate informed consent regarding TD risk when prescribing antipsychotics 4

Special Considerations

• Anticholinergic medications: While helpful for acute dystonia and parkinsonism, they may worsen TD 3
• Withdrawal dyskinesia: May occur with either gradual or sudden cessation of neuroleptic agents but typically resolves over time 1
• Persistent TD: May not resolve even after medication discontinuation, highlighting the importance of prevention 1
• Risk factors: Up to 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia 1

Treatment Algorithm Based on Dyskinesia Type

1. For tardive dyskinesia:

   • First: Attempt to discontinue or reduce the offending medication 4
   • Second: Switch to an atypical antipsychotic if continued treatment necessary 4
   • Third: Consider VMAT2 inhibitors for persistent symptoms 2

2. For drug-induced parkinsonism:

   • First: Consider anticholinergic agents or amantadine 1
   • Second: Reduce dose or switch to an antipsychotic with lower propensity for parkinsonism 3

3. For akathisia:

   • First: Lower the antipsychotic dose if possible 1
   • Second: Consider β-blockers or benzodiazepines 1

4. For acute dystonia:

   • Immediate treatment with anticholinergic or antihistaminic medications 1

Remember that the concern over TD should not outweigh the potential benefits of antipsychotics for patients who genuinely need these medications, but careful monitoring and early intervention are essential 4.