expert roundtables

Practice Guidelines on Tardive Dyskinesia

by Leslie Citrome, MD, MPH; Andrew J. Cutler, MD; and Rakesh Jain, MD, MPH

Overview

Contemporary guidelines on the management of tardive dyskinesia (TD) include updated screening recommendations and reflect the US Food and Drug Administration (FDA) approval of the vesicular monoamine transporter 2 (VMAT2) inhibitors for the treatment of TD.

Q:

What points would you emphasize from the current TD management guidelines? 

Leslie Citrome, MD, MPH

Clinical Professor
Department of Psychiatry and Behavioral Sciences
New York Medical College
Valhalla, NY

“Encouraging physicians to be aware of the AIMS and to be familiar with how to use it will go a long way toward advancing the appropriate identification of dyskinetic movements and helping to monitor the response to TD treatment over time.”

Leslie Citrome, MD, MPH

One of the fundamental features of treatment guidelines such as those for schizophrenia is that they emphasize the need for observation, including a baseline assessment of movement disorders. When caring for a patient with schizophrenia, it is important to assess for TD at baseline and to conduct structured assessments at periodic intervals during treatment.

The Abnormal Involuntary Movement Scale (AIMS) has been in use for many years, and some agencies have adopted it as a requirement; however, one of the unmet needs in clinical practice is to increase awareness that the AIMS is a clinician-friendly scale to assess TD. It is also the primary outcome employed in clinical research on treatments for TD. It is relatively rare to see the same scale used in both the clinic and research settings. Encouraging physicians to be aware of the AIMS and to be familiar with how to use it will go a long way toward advancing the appropriate identification of dyskinetic movements and helping to monitor the response to TD treatment over time. 

This approach to assessment is similar to the one taken to measure care for major depressive disorder (MDD), which encourages the use of a scale such as the Patient Health Questionnaire-9 for patients to rate themselves at baseline and then periodically, which can help to ensure that the relevant symptoms are treated.

Looking to the future, treatment guidelines for mood disorders such as MDD and bipolar disorder would likely benefit from the inclusion of more TD-directed content. These are populations for which antipsychotics are also approved by the FDA, but much of the guidance on TD to date has been specific to TD in schizophrenia.

Rakesh Jain, MD, MPH

Clinical Professor
Department of Psychiatry
Texas Tech University Health Sciences Center School of Medicine - Permian Basin
Midland, TX

“The APA guidelines for schizophrenia and the modified Delphi guidelines converge on recommendations for TD screening and on the need to strongly consider the AIMS as the gold standard for assessing TD.”

Rakesh Jain, MD, MPH

The American Psychiatric Association (APA) guidelines for schizophrenia and the modified Delphi guidelines converge on recommendations for TD screening and on the need to strongly consider the AIMS as the gold standard for assessing TD. The guidelines also agree on the importance of looking for biopsychosocial impairment related to TD and not just for the presence of TD, as well as on the need to avoid anticholinergics in patients with TD. Finally, both guidelines agree on the very strong recommendation for the first-line use of the VMAT2 inhibitors valbenazine and deutetrabenazine in patients with TD.

Dr Citrome highlighted the needs related to TD awareness in patients with MDD and bipolar disorder, and I agree that these are vulnerable populations. In addition, geriatric patients are particularly vulnerable to developing TD. Often, they do not have schizophrenia, but they do have a variety of other conditions for which they receive dopamine receptor–blocking agents (DRBAs), and their risk of developing TD is quite high. At the other end of the age spectrum are younger patients with developmental disorders (eg, autism spectrum disorder) or a variety of other conditions that are associated with cognitive impairments in whom the use of DRBAs is also very high. That population is also substantially at risk for developing TD.

Andrew J. Cutler, MD

Clinical Associate Professor of Psychiatry
SUNY Upstate Medical University
Lakewood Ranch, FL
Chief Medical Officer
Neuroscience Education Institute
Carlsbad, CA

“[The 2021 APA guidelines for schizophrenia] recommend VMAT2 inhibitors as first-line treatments for patients with moderate to severe TD, also noting that these agents can be considered in those with mild TD on the basis of patient preference, associated impairment, or effect on psychosocial functioning.

Andrew J. Cutler, MD

My colleagues have nicely highlighted key features of the current guidelines, and I think that the evolution that led to the present-day guidance on TD provides some additional context. Back in 2013, the American Academy of Neurology released treatment guidelines for TD, and, at that time, no treatments were supported by level A evidence and no medications were FDA approved for the treatment of TD. At that time, clonazepam and Ginkgo biloba had level B recommendations.

In 2017, the VMAT2 inhibitors valbenazine and deutetrabenazine were approved by the FDA for the treatment of TD. In 2018, an updated review from the lead author of the American Academy of Neurology 2013 guidelines described them as being “established as effective treatments of TD (Level A) and must be recommended as treatment.”

The 2021 APA guidelines for schizophrenia were not specifically dedicated to TD, but they do include sections that are relevant to it; they recommend VMAT2 inhibitors as first-line treatments for patients with moderate to severe TD, also noting that these agents can be considered in those with mild TD on the basis of patient preference, associated impairment, or effect on psychosocial functioning. Patients with relatively mild TD may be highly embarrassed by the dyskinetic movements, and this may really limit their function. Thus, clinicians may choose to treat these patients with a VMAT2 inhibitor.

The APA guidelines for schizophrenia also changed regarding the screening and monitoring for TD during treatment. This is a very important change that should raise awareness of TD, which is currently vastly underdiagnosed. In previous iterations, the recommended frequency for evaluating TD was once or twice per year. The new guidelines recommend screening for TD at every clinical encounter with any patient on an antipsychotic or a DRBA. Clinicians need not conduct a full structured evaluation such as the AIMS at every encounter, but they should at least inquire at each visit. Formal structured examinations such as the AIMS should still be conducted at least once or twice per year.

References

American Psychiatric Association. The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd edition. American Psychiatric Association; 2021.

Bhidayasiri R, Fahn S, Weiner WJ, Gronseth GS, Sullivan KL, Zesiewicz TA; American Academy of Neurology. Evidence-based guideline: treatment of tardive syndromes: report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2013;81(5):463-469. doi:10.1212/WNL.0b013e31829d86b6

Bhidayasiri R, Jitkritsadakul O, Friedman JH, Fahn S. Updating the recommendations for treatment of tardive syndromes: a systematic review of new evidence and practical treatment algorithm. J Neurol Sci. 2018;389:67-75. doi:10.1016/j.jns.2018.02.010

Caroff SN, Citrome L, Meyer J, et al. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81(2):19cs12983. doi:10.4088/JCP.19cs12983

Ricciardi L, Pringsheim T, Barnes TRE, et al. Treatment recommendations for tardive dyskinesia. Can J Psychiatry. 2019;64(6):388-399. doi:10.1177/0706743719828968

More in Tardive Dyskinesia

Thumb

Tardive Dyskinesia

Expert Perspectives in Tardive Dyskinesia to Cover Key Topics in Tardive Dyskinesia Treatment

Expert Perspectives

Expert Perspectives delivers health care providers with insights from key thought leaders on the latest advancements and current practices in medic...READ MORE

Thumb

Tardive Dyskinesia

Early Recognition of the Clinical Features of Tardive Dyskinesia

Patient Care Perspectives by Rakesh Jain, MD, MPH

Prevention, close monitoring, and the earliest possible diagnosis are all critical aspects of optimizing outcomes in tardive dyskinesia (TD). The A...READ MORE

Thumb

Tardive Dyskinesia

Refractory or Difficult-to-Treat Tardive Dyskinesia

Patient Care Perspectives by Rakesh Jain, MD, MPH

Our featured expert notes the importance of optimizing the use of vesicular monoamine transporter 2 (VMAT2) inhibitors and addressing comorbidities...READ MORE

More In Psychiatry

Tardive Dyskinesia

Central Dopamine Blockade in the Pathophysiology of Tardive Dyskinesia

Expert Roundtables by Leslie Citrome, MD, MPH; Andrew J. Cutler, MD; and Rakesh Jain, MD, MPH

Tardive Dyskinesia

Dopamine Receptor–Blocking Agent Exposure in the Pathophysiology of Tardive Dyskinesia

Clinical Topic Updates by Andrew J. Cutler, MD

Tardive Dyskinesia

Antipsychotic Switching Strategies in Tardive Dyskinesia

Clinical Topic Updates by Andrew J. Cutler, MD