Propranolol for Tardive Dyskinesia
Propranolol may be considered as a third-tier treatment option for tardive dyskinesia when first-line VMAT2 inhibitors are unavailable or ineffective, though the evidence supporting its use is limited and inconsistent. 1, 2
Evidence Quality and Treatment Hierarchy
The management of tardive dyskinesia follows a clear hierarchy based on evidence strength:
First-Line Approaches
- Withdraw the offending antipsychotic if clinically feasible - this remains the primary management strategy when the underlying psychiatric condition allows 3, 4
- Switch to atypical antipsychotics with lower D2 affinity (clozapine or quetiapine) if antipsychotic therapy must continue 4
- VMAT2 inhibitors (valbenazine and deutetrabenazine) have Level A evidence and FDA approval specifically for tardive dyskinesia, making them the recommended first-choice pharmacologic agents 2, 5
Propranolol's Position in Treatment
Propranolol is classified as a third-tier agent with insufficient evidence to recommend it routinely 2. The data supporting its use consists of:
One retrospective case series (2016) examining 47 patients showed 64% had some improvement, with 77% of responders achieving moderate to near-complete response 1
- Mean daily dose was only 69 mg
- Duration of therapy averaged 14 months
- Three patients discontinued due to adverse effects: hypotension (2 patients) and nightmares (1 patient)
- Severity of TD and duration of propranolol therapy predicted response 1
One older double-blind study (1982) showed no short-term improvement, though 2 of 4 subjects responded to long-term use 6
Clinical Considerations for Propranolol Use
When to consider propranolol:
- VMAT2 inhibitors are unavailable (not approved in Canada) or unaffordable 4
- Second-tier agents (clonazepam, Ginkgo biloba, amantadine) have failed or are contraindicated 2
- Patient has moderate to severe TD symptoms 1
- No contraindications exist (hypotension, bradycardia, bronchospasm, heart block) 1
Dosing approach:
- Start with low doses (the effective mean dose in the retrospective study was 69 mg daily) 1
- Expect delayed response - benefits may require months of therapy rather than weeks 1, 6
- Monitor blood pressure and heart rate closely given hypotension risk 1
Critical Limitations
The evidence for propranolol is weak - it lacks randomized controlled trials and relies primarily on one retrospective case series and older case reports 1, 2, 6. This contrasts sharply with VMAT2 inhibitors, which have Level A evidence from multiple randomized controlled trials 2, 5.
Prevention remains paramount since treatment options remain limited even with newer agents 3, 4. Use atypical antipsychotics when possible, perform baseline movement assessments before starting antipsychotics, and monitor with standardized scales (AIMS) every 3-6 months 3.