Might Ingrezza (valbenazine) help a patient with movement disorders and tremors, particularly if they have a confirmed diagnosis of tardive dyskinesia?

Ingrezza (Valbenazine) for Confirmed Tardive Dyskinesia

Yes, Ingrezza (valbenazine) is specifically indicated and should be used for patients with confirmed moderate to severe tardive dyskinesia, as it is FDA-approved for this indication and represents first-line pharmacotherapy according to current guidelines. 1, 2, 3

When Valbenazine Is Appropriate

For confirmed tardive dyskinesia that is moderate to severe or disabling, valbenazine is the recommended first-line pharmacological treatment. 1, 2 The American Psychiatric Association specifically endorses VMAT2 inhibitors (valbenazine or deutetrabenazine) as the primary pharmacotherapy option. 1, 2

Key Clinical Considerations:

• Valbenazine is FDA-approved specifically for tardive dyskinesia and demonstrated statistically significant improvement in the AIMS dyskinesia total score at 80 mg daily dosing. 3

• The effect size is clinically meaningful - 40% of patients on valbenazine 80 mg/day achieved ≥50% reduction in AIMS dyskinesia score versus only 8.7% on placebo, yielding a number needed to treat (NNT) of 4. 4

• Onset of benefit occurs within 2 weeks of treatment initiation, with once-daily dosing providing practical advantages. 5

Critical Diagnostic Distinction

Before prescribing valbenazine, confirm the diagnosis is actually tardive dyskinesia and not another movement disorder. 6 This distinction is essential because:

• Classic tardive dyskinesia involves choreiform and athetoid movements (rapid involuntary facial movements, grimacing, chewing, tongue movements), NOT tremor as a primary feature. 6

• If tremor is the predominant symptom, consider drug-induced parkinsonism instead, which presents with bradykinesia, tremors, and rigidity - this condition responds to anticholinergic agents like benztropine, whereas TD does not. 6

• Anticholinergic medications are contraindicated for tardive dyskinesia and may actually worsen the condition. 2

Treatment Algorithm

1. Confirm TD diagnosis using clinical observation and baseline AIMS scoring before initiating treatment. 1

2. Assess severity - valbenazine is specifically recommended for moderate to severe or disabling TD. 1, 2

3. If clinically feasible, gradually withdraw the offending antipsychotic as the primary intervention when the underlying psychiatric condition allows. 2

4. If antipsychotic continuation is necessary, consider switching to atypical antipsychotics with lower D2 receptor affinity, or preferably clozapine, which has the lowest risk profile for movement disorders. 1

5. Initiate valbenazine 80 mg daily as first-line pharmacotherapy for persistent moderate to severe TD. 3, 4

6. Monitor response using AIMS at regular intervals (at least every 3-6 months). 2

Safety Profile

• Discontinuation due to adverse events is rare - only 2.9% for valbenazine versus 1.6% for placebo (NNH of 76, not statistically significant). 4

• Somnolence is the primary side effect (10.9% vs 4.2% placebo), with an NNH of 15. 4

• QT interval prolongation is possible, requiring ECG monitoring consideration. 4

• Valbenazine is approximately 15 times more likely to result in clinical response than discontinuation due to adverse events. 4

Common Pitfalls to Avoid

• Do not use valbenazine for tremor-predominant presentations - these likely represent drug-induced parkinsonism, not TD. 6

• Never use anticholinergic medications (benztropine, trihexyphenidyl) for TD - they are contraindicated and may worsen symptoms. 2

• Do not delay treatment - TD may persist or become irreversible even after medication discontinuation, making early intervention critical. 1