What is the diagnosis and treatment for Tardive Dyskinesia (involuntary movement disorder)?

From the Guidelines

Tardive dyskinesia should be managed by first considering discontinuation or dose reduction of the causative medication if clinically appropriate, or switching to an antipsychotic with lower risk such as quetiapine or clozapine, as recommended by the American Academy of Child and Adolescent Psychiatry 1.

Key Considerations

• Tardive dyskinesia is a major public health concern in the treatment of schizophrenia, with both clinical and medicolegal implications 1.
• The condition is typically associated with the long-term use of neuroleptics, and withdrawal dyskinesia may occur with either gradual or sudden cessation of neuroleptic agents 1.
• As many as 50% of youth receiving neuroleptics may experience some form of tardive or withdrawal dyskinesia, highlighting the need for careful monitoring and management 1.

Prevention and Management

• Prevention is crucial through using the lowest effective dose of antipsychotics, regular monitoring for early signs of movement disorders, and considering alternative treatments when possible 1.
• The Abnormal Involuntary Movement Scale (National Institute of Mental Health, 1985) is a useful measure for monitoring this problem 1.
• If tardive dyskinesia occurs, the medication should be continued at the current dose only if the patient is in full remission and there is reason to believe that any change in dosage or agent will precipitate a relapse 1.

Treatment Options

• Atypical antipsychotic agents, such as risperidone, olanzapine, and quetiapine, have a lower risk of extrapyramidal symptoms and tardive dyskinesia compared to typical antipsychotic agents 1.
• FDA-approved treatments for established tardive dyskinesia include valbenazine and deutetrabenazine, which are VMAT2 inhibitors that reduce dopamine release in the brain.

Important Considerations

• The concern over tardive dyskinesia should not outweigh the potential benefits provided by antipsychotics for patients with schizophrenia, but adequate informed consent is necessary, and baseline measures of abnormal movements should be recorded 1.
• Regular monitoring for early signs of movement disorders is essential to prevent and manage tardive dyskinesia effectively.

From the FDA Drug Label

Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to rely upon prevalence estimates to predict, at the inception of antipsychotic treatment, which patients are likely to develop the syndrome. Whether antipsychotic drug products differ in their potential to cause tardive dyskinesia is unknown The risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase However, the syndrome can develop, although much less commonly, after relatively brief treatment periods at low doses or may even arise after discontinuation of treatment. Tardive dyskinesia may remit, partially or completely, if antipsychotic treatment is withdrawn Antipsychotic treatment, itself, however, may suppress (or partially suppress) the signs and symptoms of the syndrome and thereby may possibly mask the underlying process. If signs and symptoms of tardive dyskinesia appear in a patient on quetiapine, drug discontinuation should be considered. However, some patients may require treatment with quetiapine despite the presence of the syndrome.

Tardive Dyskinesia is a potential side effect of antipsychotic treatment, including quetiapine. The risk of developing tardive dyskinesia increases with:

• Duration of treatment
• Total cumulative dose of antipsychotic drugs However, it can also occur after brief treatment periods or low doses, or even after discontinuation of treatment. Discontinuation of treatment should be considered if signs and symptoms of tardive dyskinesia appear, but some patients may still require treatment despite the presence of the syndrome 2.

Tardive dyskinesia (TD) has occurred in patients treated with antipsychotic drugs, including clozapine. The syndrome consists of potentially irreversible, involuntary, dyskinetic movements. The risk of TD and the likelihood that it will become irreversible are believed to increase with greater durations of treatment and higher total cumulative doses However, the syndrome can develop after relatively brief treatment periods at low doses. Prescribe clozapine in a manner that is most likely to minimize the risk of developing TD. Use the lowest effective dose and the shortest duration necessary to control symptoms.

Tardive Dyskinesia is also a potential side effect of clozapine. The risk of developing TD increases with:

• Duration of treatment
• Total cumulative dose of antipsychotic drugs To minimize the risk, clozapine should be prescribed at the lowest effective dose and for the shortest duration necessary to control symptoms 3.

From the Research

Definition and Overview of Tardive Dyskinesia

• Tardive dyskinesia (TD) is a movement disorder characterized by irregular, stereotyped, and choreiform movements associated with the use of antipsychotic medication 4.
• It is a late-appearing extrapyramidal disorder of involuntary, choreoathetoid movements that may appear during chronic treatment with classical neuroleptics or a short time after its prolonged administration is interrupted 5.
• TD is a debilitating, iatrogenic, and potentially severe movement disorder characterized by involuntary, repetitive, purposeless movements that are present throughout the body 6.

Prevention and Management of Tardive Dyskinesia

• Preventing TD is of primary importance, and clinicians should follow best practice for prescribing antipsychotic medication, including limiting the prescription for specific indications, using the minimum effective dose, and minimizing the duration of therapy 4.
• The first-line management of TD is the withdrawal of antipsychotic medication if clinically feasible 4.
• Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine, may be effective in reducing TD symptoms 4, 5.
• The strongest evidence for a suitable co-intervention to treat TD comes from tests with the new VMAT inhibitors, deutetrabenazine and valbenazine 4.

Treatment Options for Tardive Dyskinesia

• For mild dyskinesia, low doses of a benzodiazepine (e.g., clonazepam) may reduce the amount of both dyskinesia and associated anxiety 7.
• Anticholinergic drugs are unhelpful and may aggravate TD, but may be effective in tardive dystonia 7.
• Botulinum toxin injections are of considerable value in managing localized forms of tardive dystonia, such as retrocollis or blepharospasm 7.
• Tetrabenazine and reserpine are presynaptic dopamine depletors that may have considerable efficacy in TD, especially tardive dystonia; however, their use is often limited by side effects 7.
• Quetiapine has been shown to be effective in reducing TD symptoms in some cases 5.
• Other treatment options, such as deep brain stimulation and repetitive transcranial magnetic stimulation, are being explored 6.

Importance of Early Recognition and Assessment

• Early recognition and assessment of TD are crucial for effective management 6.
• The manifestations of TD should be documented, and the patient should be examined to exclude other possible causes of dyskinesia 7.
• Psychiatric reevaluation to consider alternative psychiatric diagnoses or treatments is strongly advised 7.