Ingrezza for Tremors: Not the Right Indication
Ingrezza (valbenazine) is FDA-approved specifically for tardive dyskinesia, not tremors—classic tardive dyskinesia involves choreiform (dance-like) and athetoid (writhing) movements, not tremor as a primary feature. 1
Understanding What Ingrezza Treats
Ingrezza targets involuntary movements characteristic of tardive dyskinesia, which typically presents as:
- Rapid involuntary facial movements including blinking, grimacing, chewing, or tongue movements 1
- Choreiform and athetoid movements affecting the orofacial region primarily, but potentially involving any body part 1, 2
- Not tremor as the predominant symptom 1
FDA-Approved Indication and Evidence
The FDA approved Ingrezza specifically for treating adults with tardive dyskinesia based on controlled trials showing significant improvement in involuntary dyskinetic movements, not tremor. 3
- In the pivotal trial, Ingrezza 80 mg daily demonstrated a clinically significant effect size (d=0.90) for reducing tardive dyskinesia symptoms as measured by the Abnormal Involuntary Movement Scale (AIMS) 4
- The AIMS scale assesses involuntary movements across body regions, focusing on choreiform movements, not tremor 3
- Both the American Psychiatric Association and American Academy of Neurology recommend VMAT2 inhibitors (valbenazine or deutetrabenazine) as first-line pharmacotherapy specifically for moderate to severe tardive dyskinesia 1
Critical Distinction: Rule Out Other Movement Disorders
Before considering any treatment, you must differentiate between movement disorder types:
- Tardive dyskinesia: choreiform/athetoid movements (what Ingrezza treats) 1
- Drug-induced parkinsonism: tremor, rigidity, bradykinesia (requires different management) 5
- Acute dystonia: sustained muscle contractions 1
- Akathisia: restlessness and inability to sit still 1
What to Do If Your Patient Has Tremor
If the patient has tremor rather than choreiform movements:
- Do not use Ingrezza—it is not indicated for tremor and will not be effective 1, 3
- Identify the tremor type (resting, action, intention) and underlying cause
- Consider whether this is drug-induced parkinsonism from antipsychotics, which may benefit from anticholinergics (unlike tardive dyskinesia where anticholinergics worsen symptoms) 5
- If on antipsychotics, consider switching to atypical agents with lower D2 affinity or clozapine, which has the lowest movement disorder risk 1
When Ingrezza IS Appropriate
Use Ingrezza only when you have confirmed tardive dyskinesia with characteristic involuntary choreiform movements, not tremor. 5, 1, 3