Valbenazine for Tardive Dyskinesia
For moderate to severe tardive dyskinesia, start valbenazine at 40 mg once daily for one week, then increase to the recommended dose of 80 mg once daily. 1
Dosing Algorithm
Standard Dosing
- Initial dose: 40 mg once daily 1
- After 1 week: Increase to 80 mg once daily (recommended maintenance dose) 1
- Alternative maintenance doses: 40 mg or 60 mg once daily may be considered based on individual response and tolerability 1
- Administration: Can be taken with or without food 1
Special Populations
Hepatic Impairment:
- Patients with moderate or severe hepatic impairment should remain at 40 mg once daily 1
CYP2D6 Poor Metabolizers:
- Known poor metabolizers should remain at 40 mg once daily 1
Clinical Context and Evidence
Valbenazine is a VMAT2 inhibitor and represents first-line pharmacotherapy for moderate to severe or disabling tardive dyskinesia according to the American Psychiatric Association 2. This medication became the first FDA-approved treatment specifically indicated for TD in 2017 3, 4.
Key Advantages
- Rapid onset: Treatment effect apparent within 2 weeks of initiation 3
- Once-daily dosing: Simplifies adherence compared to other regimens 3
- Sustained efficacy: Long-term studies demonstrate maintained improvement, with 89-90% of patients achieving ≥50% improvement in AIMS scores at 48 weeks 5
Expected Outcomes
- Mean improvement in AIMS total score at week 48: -10.2 with 40 mg and -11.0 with 80 mg 5
- The 60 mg dose produces predicted mean AIMS improvement of -2.69, falling between the 40 mg (-1.92) and 80 mg (-3.39) responses 6
- After washout, scores return toward baseline, indicating ongoing need for treatment 7, 5
Safety Profile
Common Considerations:
- Generally well tolerated in long-term use (up to 48 weeks) 7, 5
- Serious adverse events occurred in 13.7-14.6% during extended treatment 7, 5
- Discontinuation due to adverse events: 11.8-15.7% 7, 5
- Does not appear to induce or worsen akathisia or parkinsonism 7
- No apparent risk for suicidal ideation or behavior 7
- Patients generally remain psychiatrically stable during treatment 7
Important Clinical Pitfalls
Avoid anticholinergic medications for tardive dyskinesia treatment, as these are indicated for acute dystonia and parkinsonism, not TD 2. This is a common error in TD management.
Do not delay treatment in moderate to severe cases—valbenazine should be initiated promptly as first-line therapy rather than attempting medication switches alone 2.
Monitor for dose adequacy at the 1-week mark and adjust to 80 mg unless contraindicated by hepatic impairment or CYP2D6 poor metabolizer status 1.
Formulation Options
INGREZZA SPRINKLE capsules may be: