Can quetiapine (quetiapine) 25mg cause tardive dyskinesia, especially in vulnerable populations such as the elderly or those with a history of prolonged antipsychotic use?

Can Quetiapine 25mg Cause Tardive Dyskinesia?

Yes, quetiapine 25mg can cause tardive dyskinesia, though the risk is lower compared to typical antipsychotics and some other atypical agents. The FDA explicitly warns that tardive dyskinesia can develop "after relatively brief treatment periods at low doses" with quetiapine 1.

Understanding the Risk Profile

Quetiapine carries a lower—but not zero—risk of tardive dyskinesia (TD) compared to typical antipsychotics and higher-potency atypical agents. 2 The American Academy of Child and Adolescent Psychiatry classifies quetiapine among atypical antipsychotics with lower extrapyramidal symptom risk, alongside olanzapine and clozapine 2. However, the FDA label is unequivocal: "A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs, including quetiapine" 1.

Key Risk Factors

The FDA emphasizes that TD risk increases with:

• Duration of treatment and cumulative dose 1
• Elderly patients, especially elderly women (highest prevalence) 1
• History of prolonged antipsychotic use 3

However, the critical caveat is that TD "can develop, although much less commonly, after relatively brief treatment periods at low doses or may even arise after discontinuation of treatment." 1 This means even 25mg doses carry some risk, particularly in vulnerable populations.

Vulnerable Populations at Higher Risk

Elderly Patients

The elderly face substantially elevated TD risk with any antipsychotic, including low-dose quetiapine. 3, 1 The American Academy of Family Physicians notes that quetiapine "still carries risk for causing or perpetuating movement disorders, as it remains a dopamine receptor-blocking agent" 3. In elderly dementia patients specifically, the American Geriatrics Society recommends using antipsychotics only when patients are "severely agitated or distressed and threatening substantial harm to self or others" after behavioral interventions have failed 4.

Patients with Prior Antipsychotic Exposure

Prior exposure to typical antipsychotics or high-potency atypicals significantly increases TD risk, even when switching to lower-risk agents like quetiapine. 2, 3 The American Academy of Child and Adolescent Psychiatry reports that approximately 5% per year of young patients on antipsychotics develop TD, with cumulative risk increasing over time 2.

Clinical Evidence: Paradoxical Findings

Interestingly, research suggests quetiapine may actually improve existing TD in some patients, though it can still cause TD de novo. A randomized trial comparing quetiapine to haloperidol showed quetiapine significantly improved TD symptoms, with 64% response rate at 6 months versus 37% with haloperidol 5. Multiple case reports document TD improvement when switching from other antipsychotics to quetiapine 6, 7, 8.

However, at least one case report documents TD developing specifically during quetiapine treatment 9, confirming that quetiapine itself can cause TD despite its lower risk profile.

Prevention and Monitoring Strategy

Prescribing Approach

The FDA mandates that quetiapine "should be prescribed in a manner that is most likely to minimize the occurrence of tardive dyskinesia." 1 This means:

• Reserve chronic treatment for patients with chronic illness known to respond to antipsychotics, where alternative treatments are unavailable or inappropriate 1
• Use the smallest dose and shortest duration producing satisfactory clinical response 1
• Reassess the need for continued treatment periodically 1

Monitoring Protocol

Baseline and regular monitoring for TD is essential, even at low doses. 3 The American Academy of Child and Adolescent Psychiatry recommends:

• Baseline assessment of abnormal movements before starting therapy 3
• Regular monitoring at least every 3-6 months using standardized measures like the Abnormal Involuntary Movement Scale (AIMS) 3
• Document baseline movement examination to facilitate early detection 2

What to Monitor For

TD typically involves choreiform or athetoid movements of the orofacial region but can affect any body part. 2, 3 Look for:

• Rapid involuntary facial movements including blinking, grimacing, chewing, or tongue movements 3
• Involuntary movements of limbs or trunk 3

Management if TD Develops

If signs of TD appear, drug discontinuation should be considered, though some patients may require continued treatment despite TD presence. 1 The American Academy of Child and Adolescent Psychiatry recommends:

• Gradually withdraw the offending antipsychotic if clinically feasible 3
• Consider switching to atypical antipsychotics with lower D2 affinity 3
• For moderate to severe TD, treat with VMAT2 inhibitors (valbenazine or deutetrabenazine) as first-line pharmacotherapy 3

Critical Pitfalls to Avoid

Do not assume low doses eliminate TD risk entirely. The FDA explicitly states TD can occur "after relatively brief treatment periods at low doses" 1. Even 25mg carries some risk, particularly in elderly patients or those with prior antipsychotic exposure.

Do not use anticholinergic medications for TD. 3 The American Psychiatric Association advises against anticholinergics for TD, as they are indicated for acute dystonia and parkinsonism, not tardive dyskinesia 3.

Do not delay monitoring because of the low dose. Regular AIMS assessments every 3-6 months are essential regardless of dose 3, as early detection allows for intervention before TD becomes irreversible.