From the Guidelines
Tardive dyskinesia symptoms should be managed by discontinuing the causative medication, and if necessary, switching to an atypical antipsychotic, as the condition can persist even after discontinuation of the medication 1. Tardive dyskinesia (TD) is characterized by involuntary, repetitive movements that typically affect the face, mouth, and tongue, but can also involve the trunk and extremities. Common symptoms include:
- Lip smacking
- Tongue protrusion
- Grimacing
- Blinking
- Chewing movements
- Jaw clenching Patients may also experience rhythmic movements of the arms, legs, fingers, and toes, as well as swaying motions of the trunk or hips. These movements are often rhythmic, purposeless, and cannot be controlled voluntarily. TD is primarily caused by long-term use of dopamine receptor blocking agents, particularly first-generation antipsychotics, but can also occur with second-generation antipsychotics and certain antiemetics like metoclopramide 1. The condition develops due to dopamine receptor hypersensitivity after prolonged blockade. Symptoms may persist even after discontinuation of the causative medication and can sometimes be permanent. Early recognition is crucial, as management typically involves medication adjustment, possibly switching to an antipsychotic with lower TD risk, or adding VMAT2 inhibitors. Regular screening for TD symptoms using tools like the Abnormal Involuntary Movement Scale (AIMS) is recommended for patients on antipsychotic medications 1. If TD 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. Otherwise, attempts should be made to either lower the dose or switch to another medication, most likely an atypical antipsychotic. The concern over TD should not outweigh the potential benefits provided by antipsychotics for patients with schizophrenia, however, adequate informed consent is necessary, and baseline measures of abnormal movements should be recorded 1.
From the FDA Drug Label
Tardive Dyskinesia Variable and Fixed Dose Placebo-Controlled Trial Experience The safety of INGREZZA was evaluated in 3 placebo-controlled studies, each 6 weeks in duration (fixed dose, dose escalation, dose reduction), including 445 patients Patients were 26 to 84 years of age with moderate to severe tardive dyskinesia and had concurrent diagnoses of mood disorder (27%) or schizophrenia/ schizoaffective disorder (72%). The mean age was 56 years. Patients were 57% Caucasian, 39% African-American, and 4% other. With respect to ethnicity, 28% were Hispanic or Latino All subjects continued previous stable regimens of antipsychotics; 85% and 27% of subjects, respectively, were taking atypical and typical antipsychotic medications at study entry.
The symptoms of tardive dyskinesia include:
- Involuntary movements of the face, tongue, and limbs
- Chorea (involuntary and irregular movements)
- Dystonia (involuntary muscle contractions)
- Akathisia (restlessness and agitation) These symptoms are associated with long-term use of antipsychotic medications, and valbenazine (INGREZZA) is used to treat them 2. Deutetrabenazine (AUSTEDO) is also used to treat tardive dyskinesia, and its label warns of potential side effects such as akathisia, agitation, and restlessness 3.
From the Research
Tardive Dyskinesia Symptoms
Tardive dyskinesia (TD) is a movement disorder characterized by irregular, stereotyped, and choreiform movements associated with the use of antipsychotic medication 4. The clinical picture can be divided into orofacial, limb-truncal, and respiratory dyskinesia 5.
Clinical Presentation
- Orofacial dyskinesia: characterized by involuntary movements of the face, mouth, and tongue 5
- Limb-truncal dyskinesia: characterized by involuntary movements of the limbs and trunk 5
- Respiratory dyskinesia: characterized by involuntary movements of the respiratory muscles 5
Treatment Options
- Prevention is the best strategy, 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 6, 4
- Withdrawal of antipsychotic medication if clinically feasible 6, 4
- Switching from a first-generation to a second-generation antipsychotic with a lower D2 affinity, such as clozapine or quetiapine 6, 4
- Use of vesicular monoamine transporter 2 inhibitors, such as valbenazine and deutetrabenazine 7
- Use of other evidence-based approaches, such as deep brain stimulation and repetitive transcranial magnetic stimulation 8