Anticholinergics Should Not Be Used to Treat Tardive Dyskinesia: Insights from an Expert Panel of Psychiatry and Neurology Healthcare Professionals

Abstract: Background: Treating tardive dyskinesia (TD) with anticholinergics is a common practice, despite the lack of supportive evidence and potential to worsen TD. Methods: Eight movement disorder experts from neurology and psychiatry convened to discuss the real-world use of anticholinergics. Discussion topics included: challenges of differentiating TD from other drug-induced movement disorders (DIMDs); appropriate and inappropriate anticholinergic use in patients with DIMDs; and use of anticholinergics in select patient populations. Results: The panel emphasized that while anticholinergics can help with managing some DIMDs, current evidence indicates that they are ineffective against—and may even worsen—TD symptoms. Therefore, FDA-approved vesicular monoamine transporter 2 (VMAT2) inhibitors are recommended as first-line TD therapies. The panel noted that TD is often described as an “extrapyramidal symptom,” leading to difficulty differentiating TD from other DIMDs and inappropriate treatment of TD with anticholinergics. The panel agreed that prophylactic anticholinergic use is appropriate in patients at high risk of acute dystonia. They cautioned against chronic anticholinergic use, especially in elderly patients and those with cognitive disorders or substance abuse problems. Abrupt anticholinergic discontinuation can result in cholinergic rebound, characterized by sleep disturbances, gastrointestinal problems, urinary urgency, and DIMD manifestations. Therefore, the experts noted that if needed, anticholinergics should be prescribed at minimally effective doses and slowly tapered whenever it is safely possible. Conclusions: These findings align with the current TD treatment guidelines and highlight the need for continued education on DIMD differentiation, inappropriate and appropriate use of anticholinergics, and safe anticholinergic dosing until discontinuation is possible.Short Description: Tardive dyskinesia (TD) is a persistent and often disabling movement disorder associated with dopamine receptor blocking agents. Treating TD with anticholinergics is common, despite a lack of supportive evidence and the availability of FDA-approved TD medications. Based on two virtual meetings with movement disorder experts from neurology and psychiatry, key recommendations are presented regarding TD differentiation, inappropriate prophylactic and chronic use of anticholinergics, treatment considerations in high-risk patients, and safe anticholinergic discontinuation.Name of Sponsoring Organization(s): Neurocrine Biosciences, Inc.