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How the Experts Manage Tardive Dyskinesia
There are a few things that we all agree on, as reflected in a recent consensus statement.
Not long ago the expert consensus on tardive dyskinesia (TD) was that-aside from stopping the antipsychotic-it was not treatable.1 That has changed since the release of the new VMAT2 inhibitors: deutetrabenazine (Austedo) and valbenazine (Ingrezza) in 2017. Guidelines are being updated to incorporate these advances, and a recent Delphi consensus statement is a step in that direction. The group surveyed 29 physicians with expertise in TD: 23 psychiatrists and 6 neurologists. Here is what they have agreed on so far.2
1. Major risk factors for TD include treatment with first-generation antipsychotics, older age, and longer cumulative exposure to antipsychotics (100% agreement).
2. At least one month of antipsychotic exposure is necessary before TD can be diagnosed (70% agreement).
1. Anyone taking an antipsychotic or other dopamine receptor blocker should be screened for TD (100% agreement).
2. The Abnormal Involuntary Movement Scale (AIMS) is the gold-standard for assessment of TD (100% agreement).
3. A basic level of severity is necessary to diagnose TD. Most agreed (89%) that an AIMS score >2 (mild) affecting at least one area of the body was a reasonable cut-off for possible TD.
4. Although the mouth and eyes (orofacial musculature) are the most commonly affected area, other parts of the body need to be evaluated as well (such as the hands, feet, and other areas specified on the AIMS) (93% agreement).
1. Treatment options should be discussed with the patient and/or caregivers (100% agreement). Reasonable approaches include:
A. Changing the antipsychotic regimen (such as switching, lowering, or tapering off) (100% agreement).
B. A VMAT2 inhibitor: valbenazine (Ingrezza) or deutetrabenazine (Austedo) (100% agreement).
C. Reduction of anticholinergics such as benztropine (Cogentin) (86% agreement).
It is telling that reduction of anticholinergics made the list. Some of these, such as benztropine (Cogentin), are useful for Parkinsonian side effects on antipsychotics, but they can make TD worse, a warning that even appears in benztropine’s prescribing information.3 Anticholinergics are particularly risky in the elderly, a population that is also at higher risk for TD. These agents can cause falls, constipation, urine retention, temperature imbalance, cognitive impairment, delirium, and dementia.4 A surprising number of medicines have anticholinergic properties, including alprazolam (Xanax) and carbamazepine (Equetro). Various scales have been developed to track these effects as they stack up, including one that is available online.4
The American Psychiatric Association has not updated their TD guidelines since 1992, so this new consensus statement is a step in the right direction. For more details on the points of consensus, visit the recent tardive dyskinesia treatment guide in Psychiatric Times, available as a podcast or article.
References
1. American Psychiatric Task Force on Tardive Dyskinesia. Tardive Dyskinesia: A Task Force Report of the American Psychiatric Association. Washington DC: American Psychiatric Press; 1992.
2. Caroff SN, Citrome L, Meyer J, et al. A modified delphi consensus approach to clinical guidelines for tardive dyskinesia.CNS Spectr. 2019;24:197-198.
3. Merck, Cogentin (Benztropine Mesylate Injection). Prescribing Information, 2013. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/012015s026lbl.pdf. Accessed May 30, 2019.
4. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review.BMC Geriatr. 2015;15:31.