Tardive Dyskinesia: Medication Management, Your Questions Answered

In Part 2 of this podcast, Rakesh Jain, MD, MPH, Psych Congress steering committee member, clinical professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin, Texas continues the Q&A session with Rajeev Kumar, MD, Director, Rocky Mountain Movement Disorders Center, Englewood, Colorado and Jonathan M. Meyer, MD, Clinical Professor of Psychiatry, University of California, San Diego, San Diego, California on their Psych Congress session titled "Tardive Dyskinesia Across the Complexity Spectrum – From Quality of Life Improvement to Novel Treatments."

In the previous Part 1, they discussed parkinsonism in tardive dyskinesia (TD) and creating treatment options for patients with TD.

Read the Transcript:

Dr Rakesh Jain:  Jonathan, what would you suggest if the patient who has had TD notices that she's allergic to VMAT2 drugs? I can't give any details because I don't have anything more.

Dr Jonathan M. Meyer:  All I can say is there's 2 agents out there. If you have an allergy to one, I just cross your fingers you don't have the allergy to the other one. If you're really up against it, there is generic tetrabenazine. I've not heard of this. You have more experience...

Dr Rajeev Kumar:  I have not seen anyone actually with an allergy to either medication. I guess it's possible, but I have not seen that.

Dr Jain:  OK. It might be a good idea to explore what the patient means by allergy.

Dr Meyer:  Probably intolerability like sedation or some other side effect.

Dr Jain:  The next question is about sedation. The question is, both VMAT2s on occasion can give me sedation. How should I manage it? I'll start with you then I'll come right to you.

Dr Kumar:  Sure. Here we go. This is what you do. What you can try to do is use the lowest effective dose. If your dose is not effective enough, think about switching because one patient may tolerate one VMAT2 made better than the other. I've seen this very commonly.

The other thing you can do is you can treat the sedation. My drug of choice is modafinil, armodafinil. That came as anecdotal, off-label, but I often do it. It's often helpful. Those are the other things you can do.

The other thing you can do is you might try to change your dosing strategy to every other day is valbenazine or deutetrabenezine only at night. Again, I generally don't find that strategy so helpful. More commonly dose reduction, adding a stimulant.

Dr Jain:  Yeah, I certainly endorse that. Do you endorse Rajeev's comments?

Dr Meyer:  Everything and just look for other stuff which is contributing to it. I think that's it. We give the people with schizophrenia, most people are on 5 medicines. See if there's something else which you can get rid of.

Dr Kumar:  Yeah. Look not just...

Dr Meyer:  Not the antipsychotic, by the way.

Dr Kumar:  Yeah. Don't just look for it.

Dr Meyer:  Maybe the mirtazapine can go.

Dr Kumar:  Yes, it's possible but also look for other...lot of patients use stuff like...

Dr Meyer:  Benzodiazepines. Cognitive impairing, don't make psychosis better.

Dr Jain:  Yeah, that's for sure. OK, Jonathan, this is a psychiatry question. Are there liabilities to actually documenting TD for the clinician?

Dr Meyer:  It's the opposite. Failure to diagnose is why people get into trouble. Your best friend is, as you said, give people a good risk-benefit discussion. You don’t want to scare the pants off of them.

If you think the atypical is going to help with their depression which has been tough to treat, give it to them. Describe, yes. I would even say it's relatively uncommon and as he said, he was extremely rare, but tell them what to look for. Make sure you're partners in the discussion.

The failure to diagnose, not a good strategy. Not a good strategy.

Dr Jain:  Right. That would challenge the notion of Joe's presentation or Joe's tardive dyskinesia was rare.

Dr Meyer:  Severity.

Dr Jain:  Severity, sure. The notion that this is so rare is something that often pervades psychiatry and it's worth challenging our own thinking.

Last question, but I would say it's an exceptionally important question. I'll start with you, Rajeev. Our formulary will not cover deutetrabenezine or valbenazine. Making us go through hoops. Do you have ideas what we can do to support it being prescribed?

Dr Kumar:  I think that the first thing is that you've got a clear, troublesome problem. You have an FDA-approved therapy. I think that you need to argue as best as you can. It may be a cost issue, of course. It's very interesting.

I'll tell you what I...some strategies I've done in similar situation. Not specifically with this. You're prescribing an on-label drug for an on-label condition. If I'm asked to prescribe an off-label drug like that, sometimes I will write the formulary manager, "OK. Thank you very much. Please tell me your name, etc, and contact information so I can forward this to FDA for your promotion of off-label prescribing."

Because effectively, they're telling me use an off-label drug. Just let me use generic tetrabenazine, which is not appropriate. Now, is it effective? Perhaps yes, but that's not...Or maybe you're given nothing to treat which is on-label because we're giving nothing which is on formulary. Then you're really on big trouble.

Dr Jain:  Got it.

Dr Meyer:  I would say, or worse, the recommendation which I hear from people, that you try anticholinergics.

Dr Kumar:  Which is also not indicated at all.

Dr Meyer:  That's where, on the whole, their feet is on fire as much as possible. Get a name, tell me you're going to report them. They're telling you exact opposite of what should be done medically.

Dr Jain:  In the last 30 seconds, I'll add my couple of words to it. Make sure that diagnosis is documented. Often the diagnosis is not written.

Number 2, get the AIMS score, enter it. The third, which has been incredibly helpful, put down the impairments. Joe's story is impressive not because its AIMS score is say at 22. It's impressive because of the impairments.

When you have that combination, it's a little bit easier to persuade.

I have 3 seconds that allows me to thank both of you gentlemen. Thank both of you, wonderful people for being here. Thank you dear colleagues for being at our presentation. We will see you at another session. Thank you again.