What is the next step for a patient taking Abilify (aripiprazole) 15mg for bipolar disorder for over a year who has developed new abnormal mouth movements?

Immediate Management of Tardive Dyskinesia in a Patient on Aripiprazole

Discontinue or significantly reduce the dose of aripiprazole immediately, as the patient has developed tardive dyskinesia—a potentially irreversible movement disorder that requires prompt intervention. 1

Understanding the Clinical Situation

This patient has developed new abnormal mouth movements after over a year of aripiprazole therapy, which is highly suggestive of tardive dyskinesia (TD). TD is characterized by rapid involuntary facial movements including blinking, grimacing, chewing, or tongue movements, and represents a potentially irreversible complication of antipsychotic therapy. 2, 3

The FDA labeling for aripiprazole explicitly states that TD may develop in patients treated with antipsychotic drugs, and the risk increases with duration of treatment and cumulative dose. 1 Critically, TD may not resolve even after medication discontinuation, making early recognition and intervention essential. 3, 4

Immediate Action Steps

Primary Intervention

• If clinically feasible, gradually withdraw aripiprazole. 3, 4 The FDA label specifically states: "If signs and symptoms of tardive dyskinesia appear in a patient on aripiprazole, drug discontinuation should be considered." 1

• Reassess the ongoing need for antipsychotic treatment. The need for continued treatment should be evaluated periodically, and chronic antipsychotic treatment should be reserved for patients with chronic illness that responds to antipsychotics and for whom alternative treatments are not available. 1

If Antipsychotic Treatment Must Continue

• Some patients may require continued treatment with aripiprazole despite the presence of TD, particularly if bipolar disorder is inadequately controlled and alternative treatments have failed. 1

• Consider switching to an alternative mood stabilizer or antipsychotic with lower TD risk if continued pharmacotherapy is necessary. 3, 4 The American Academy of Child and Adolescent Psychiatry recommends considering atypical antipsychotics with lower D2 receptor affinity. 3

Diagnostic Confirmation

• Document the abnormal movements using a standardized assessment tool such as the Abnormal Involuntary Movement Scale (AIMS). 3, 4 This provides objective baseline documentation and allows monitoring of progression or improvement.

• Rule out other causes of abnormal movements, including acute dystonia (which occurs early after medication initiation), akathisia (restlessness), or drug-induced Parkinsonism (which includes tremor, rigidity, and bradykinesia). 2, 4 Classic TD involves choreiform and athetoid movements, not tremor as a primary feature. 5

Pharmacological Treatment for Established TD

If TD is moderate to severe or disabling, and antipsychotic discontinuation is not feasible, the American Psychiatric Association recommends treating with a VMAT2 inhibitor (valbenazine or deutetrabenazine) as first-line pharmacotherapy. 3

• Do not use anticholinergic medications for TD, as they are indicated for acute dystonia and Parkinsonism, not tardive dyskinesia. 3

• Deutetrabenazine and valbenazine are FDA-approved specifically for TD and demonstrate efficacy in class 1 studies. 3

Critical Pitfalls to Avoid

• Do not continue the same dose of aripiprazole without addressing the TD. The FDA explicitly warns that antipsychotic treatment may suppress the signs and symptoms of TD, potentially masking the underlying process while the condition worsens. 1

• Do not assume TD will resolve with continued treatment. Up to 50% of patients receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia, and TD may persist indefinitely. 3, 4

• Avoid rapid discontinuation without a plan for managing bipolar disorder. While TD requires urgent attention, abrupt cessation of mood stabilization could precipitate a manic or depressive episode. 6, 7

Ongoing Monitoring

• Regular follow-up is essential to assess whether TD improves, stabilizes, or worsens after medication adjustment. 3

• TD may remit partially or completely if antipsychotic treatment is withdrawn, but this is not guaranteed, particularly with longer duration of exposure. 1

• If the patient requires ongoing antipsychotic therapy after TD resolution, carefully consider the risks before reintroducing any antipsychotic medication, using the smallest effective dose and shortest duration. 1