Management of tardive dyskinesia, have you mastered all these issues?

Tardive dyskinesia (TD) is a movement disorder characterized by involuntary movements of the tongue, lips, face, trunk, and extremities
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Because TD occurs most often in patients receiving long-term antidopaminergic medication, clinicians should use the lowest effective dose for the shortest possible treatment time
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First-line management of TD is to discontinue antipsychotics when feasible
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Unfortunately, for many patients with severe mental illness, it is impossible to discontinue antipsychotic medication due to relapse of the disease
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What strategies can be used to manage TD? Test your knowledge with this quick quiz
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Compiled and organized by Yimaitong, please do not reprint without authorization
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 Question 1 Which is correct regarding changes in antipsychotic treatment regimens in TD patients? A.
Increasing the dose of antipsychotic medication can often mask TD symptoms, which is the recommended approach B.
TD may initially worsen after discontinuation of antipsychotic medication C.
Since there is no risk of permanent dyskinesia, regardless of TD, Antipsychotic medication should be continued to reduce the risk of psychotic worsening D.
TD symptoms usually disappear within 3 months of discontinuation of antipsychotic medication :B
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Changing the antipsychotic medication regimen, including stopping it, is one way to treat TD
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However, clinicians and patients should be aware that, given the underlying psychiatric disorder and the availability of alternative medicines, TD may initially worsen after discontinuation of dopamine blockers if this approach is feasible
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 Reducing the dose of antipsychotics may improve TD symptoms; however, studies have shown that these benefits are contradictory and poorly understood
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Higher doses of antipsychotics may worsen drug-induced Parkinson's disease or akathisia, and TD may reappear or worsen over time
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Therefore, this practice is not recommended
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 When TD is diagnosed, if possible, reduce the dose or discontinue the causative drug
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Primary prevention of TD by using the lowest effective dose of antipsychotic drugs for the shortest possible time is recommended, and clinicians should weigh the risk of permanent dyskinesia with the risk of psychotic exacerbation
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Question 2 Which of the following about the treatment of TD is correct? A.
The treatment of TD has not been approved B.
Inhibitors of vesicular monoamine transporter 2 have been approved for the treatment of TDC.
Atypical antipsychotics have been approved for the treatment of TDD.
Vitamin D is effective in the treatment of TD ↓↓↓↓↓↓↓↓↓【Answer and Analysis】Answer:
B.

The U.
S.
Food and Drug Administration (FDA) has approved two vesicular monoamine transporter 2 (VMAT2) inhibitors for the treatment of TD in adults: valbenazine and deuterated tetrabenazine
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These drugs modulate the packaging and release of presynaptic dopamine into synapses and may ameliorate or counteract the motor-related effects of antipsychotics and other dopaminergic blockers
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 Atypical antipsychotics can replace typical antipsychotics to manage psychosis to reduce the risk of TD
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While typical antipsychotics primarily block dopamine D2 receptors, atypical antipsychotics bind to varying degrees with dopaminergic, serotonergic, alpha-adrenergic, histaminergic, and muscarinic receptors
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In particular, a switch to clozapine is recommended for patients with TD requiring antipsychotic therapy
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Clozapine is one of the most effective atypical antipsychotics for treatment-resistant schizophrenia, but it also has other adverse effects that require monitoring
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Although clozapine is associated with TD, the incidence of TD appears to be lower with clozapine and other atypical antipsychotics than with typical antipsychotics
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 There is anecdotal and mixed evidence that vitamin E (but not vitamin D) is beneficial for some people with TD
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This requires further research
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Question 3 Regarding the performance of TD, which is correct? A.
Acute dyskinesia can co-occur with TD B.
Emotional stress does not affect the performance of TD C.
Tardive dystonia occurs in at least 25% of patients receiving long-term treatment with dopamine antagonists D.
TD symptoms are There is little fluctuation during the day.
Swipe to see the answer↓↓↓↓↓↓↓↓↓【Answer and Analysis】Answer: A
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The first step in managing a TD is to identify and describe all its subjective and objective manifestations
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Patients often have dyskinesias that may present with a mixture or overlap of several involuntary movements
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Individuals receiving antipsychotic medication may exhibit both acute and chronic reactions, including acute dyskinesia and TD
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Akathisia and convulsions may co-occur after long-term use of antipsychotic drugs
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 TD can vary widely throughout the day and can worsen with emotional stress
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Likewise, the effects of TDs vary over time; therefore, assessment of TDs and their effects should be a routine part of every patient visit as part of the 2020 American Psychiatric Association Practice Guidelines for the Treatment of Patients with Schizophrenia recommended
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 In patients receiving long-term treatment with dopamine antagonists, approximately 1% to 2% of individuals develop tardive dystonia
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Question 4 Regarding anticholinergic drugs and TD, which is correct? A.
There is currently no evidence that discontinuing anticholinergics reduces the severity of TD B.
Anticholinergics are not associated with the development of TD C.
Anticholinergics may improve symptoms of TD D.
Anticholinergics may aggravate TD and its effects Scroll to see answer ↓↓↓↓ ↓↓↓↓↓【Answer and Analysis】Answer:
D.

Anticholinergic drugs may exacerbate TD and its effects
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Up to 60% of patients showed improvement in TD severity scores after discontinuation of anticholinergics
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However, caution should be exercised in deciding to attenuate anticholinergic therapy in patients with acute drug-induced exercise (eg, Parkinson's disease, dystonia) or tardive dystonia, as these disorders may recur or worsen after drug discontinuation
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Amantadine may be a reasonable and beneficial alternative to anticholinergics in patients with TD and Parkinson's disease
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Question 5 Based on the limited evidence, what other off-label approaches might be considered for patients with TD? A.
Ginkgo biloba preparations B.
Non-benzodiazepine muscle relaxants C.
Chinese herbal medicines D.
Change from typical antipsychotics to atypical antipsychotics that block dopamine receptors Scroll to see the answer ↓↓↓↓↓↓↓ ↓↓【Answer and Analysis】Answer:
D.

American Academy of Neurology (AAN) guidelines published in 2013 and reaffirmed in 2019 state that Ginkgo biloba improves TD (grade B) and can be considered for the treatment of TD
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In addition, a 2016 meta-analysis of three randomized, placebo-controlled clinical trials reported positive results for adjuvant Ginkgo biloba therapy in reducing symptoms of TD; however, more reliable data are needed to demonstrate this result, and this This method is not subject to regulatory approval
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 Studies of TD patients taking non-benzodiazepine muscle relaxants have shown no significant improvement in symptoms in TD patients compared with placebo
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In addition, patients receiving GABAergic drugs were more likely to experience worsening mental status, inability to complete studies, ataxia, or sedation
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 In a prospective observational open-label study in patients with schizophrenia, traditional Chinese medicines Yigan Powder and Jiawei Xiaoyao Powder were tested
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Although some studies have shown possible efficacy, the evidence is weak
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Compiled from: Christoph U.
Correll, Fast Five Quiz: Tardive Dyskinesia Management- Medscape - Jan 19, 2022.