Medication Management

Introduction to Tardive Dyskinesia

Tardive dyskinesia (TD) is a movement disorder characterized by involuntary, repetitive movements of the face, trunk, or limbs, associated with long-term use of neuroleptic medications (antipsychotics), which can persist even after discontinuation of the causative medication, as supported by the American Psychiatric Association and other guideline societies 1, 2, 3, 4
Common movements in TD include orofacial region movements (e.g., repetitive tongue movements, tongue protrusion) and extremities movements (e.g., choreic movements of the fingers and hands), with manifestations including dystonia, chorea, ballism, or a combination of these 1

The risk of developing TD increases with the duration of treatment and the cumulative total dose of antipsychotic medications, with up to 50% risk after 2 years of continuous use of typical antipsychotics in elderly patients, and higher prevalence in women 1, 2, 4
Older age, female gender, higher baseline AIMS scores, and intellectual impairment are factors that increase TD risk, as noted by the American Psychiatric Association 2, 4
Children and adolescents are at risk for developing tardive dyskinesia, with a point prevalence of 5-20% and higher rates for typical antipsychotics, according to the American Academy of Child and Adolescent Psychiatry 4
Early diagnosis is crucial, as the risk of persistence increases with time, and TD can remit, partially or completely, if antipsychotic treatment is withdrawn, as recommended by the American Psychiatric Association 1

The American Psychiatric Association recommends limiting exposure to dopamine receptor blocking agents when possible, using minimum effective doses of antipsychotics when required, and regular monitoring for early signs of TD using AIMS every 3-6 months 5
The American Academy of Neurology suggests documenting baseline abnormal movements before starting antipsychotics and avoiding anticholinergics (benztropine, trihexyphenidyl) as they may worsen TD symptoms 6
Regular assessment for dyskinesias should occur at least every 3-6 months using standardized tools like the Abnormal Involuntary Movement Scale, as recommended by the American Academy of Child and Adolescent Psychiatry 4

The American Psychiatric Association recommends that patients with depression and tardive dyskinesia be treated with VMAT2 inhibitors such as valbenazine or deutetrabenazine as the first-line treatment for tardive dyskinesia while maintaining appropriate antidepressant therapy 6
The American Academy of Neurology recommends valbenazine (Ingrezza) as an FDA-approved treatment for TD, with a starting dose of 40 mg daily and a target dose of 80 mg once daily, demonstrating significant reduction in TD symptoms with response rates of 33-50% 6
The National Institute of Mental Health suggests deutetrabenazine (Austedo) as an FDA-approved treatment for TD, with effective doses of 24-36 mg/day, requiring twice-daily administration with food 5
Patients with moderate to severe or disabling tardive dyskinesia associated with antipsychotic therapy should be treated with a reversible inhibitor of the vesicular monoamine transporter 2 (VMAT2) such as deutetrabenazine or valbenazine, as recommended by the American Psychiatric Association 3
The American College of Physicians recommends considering second-line agents, such as amantadine, benzodiazepines (clonazepam), ginkgo biloba, and beta-blockers, if VMAT2 inhibitors are not tolerated or available 6

Elderly patients are at higher risk for developing TD, with up to 50% developing the condition after 2 years of continuous typical antipsychotic use, as noted by the American Academy of Child and Adolescent Psychiatry 4
Patients with hepatic impairment may have contraindications to certain medications, such as deutetrabenazine, according to the American Psychiatric Association 3
Patients with Huntington's disease require careful monitoring for depression and suicidal ideation when using VMAT2 inhibitors, as recommended by the American Psychiatric Association 3
The American Academy of Child and Adolescent Psychiatry suggests balancing the risk of TD against the risk of mood disorder relapse, which can occur with lithium discontinuation 7

Anticholinergics (benztropine, trihexyphenidyl) should be avoided as they may worsen TD symptoms, according to the American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry 3, 7, 8, 4
When managing medication regimens, guidelines suggest that medications used to manage side effects (like anticholinergics for EPS) should be removed when they are no longer necessary, as recommended by the American Academy of Child and Adolescent Psychiatry 9
Abrupt discontinuation of anticholinergics should be avoided as it may lead to withdrawal symptoms or rebound effects, according to the Journal of the American Academy of Child and Adolescent Psychiatry 9
Tapering anticholinergics slowly over 1-2 weeks is essential to minimize the risk of withdrawal-emergent dyskinesia, although the exact protocol may vary, as noted by the American Academy of Child and Adolescent Psychiatry 9