Overtreatment of Tardive Dyskinesia May Cause More Side Effects

Rajeev Kumar, MD, FRCPC, medical director, Rocky Mountain Movement Disorders Center, Englewood, Colorado, answers questions about his session at the 2021 Psych Congress titled "Tardive dyskinesia across the complexity spectrum—from the quality of life improvement to novel treatments."

It is possible to overtreat tardive dyskinesia (TD), so clinicians' goal should be to manage and reduce symptoms to improve the patient's quality of life, says Dr Kumar. This video also discusses the importance of diagnosing TD early and what to do if a patient does not respond to treatment.

Read the transcript:

Dr Rajeev Kumar:  I'm Rajeev Kumar. I'm a neurologist. I specialize in movement disorders. I'm in practice in Denver, Colorado. I run a large movement disorder center that specializes in clinical trials, called Rocky Mountain Movement Disorder Center.

I've been involved with the treatment of tardive dyskinesia for more than 20 years and was an investigator in all of the pivotal trials of both valbenazine and deutetrabenazine, resulting in their approval for treatment of adults with tardive dyskinesia.

Meagan Thistle:  Why is early identification of tardive dyskinesia so critical?

Dr Kumar:  Tardive dyskinesia can have a significant impact on individuals, affecting quality of life, activities of daily living, socialization. They can cause embarrassment. It's important to explain to a patient what they're experiencing and be able to understand whether or not modification of the patient's underlying therapy is appropriate.

For example, if a patient has a primary mood, maybe has bipolar disorder, and is on an antipsychotic for mood stabilization, it may be reasonable to consider mood stabilization with a non-antipsychotic medication in order to prevent potential worsening of tardive dyskinesia.

The vast majority of patients, who have tardive dyskinesia, once it's established, will not remit, so it'd be nice to prevent further worsening. If it is impacting them, also, when you identify it, then you can help them with treatment with approved therapies.

Both deutetrabenazine and also valbenazine are approved for treatment of tardive dyskinesia. If it is affecting their quality of life, for example, may be affecting their speech, maybe causing embarrassment because they're a public-facing individual, then treatment may help them in their day-to-day activities. The earlier you identify it, the earlier you can intervene.

Ms Thistle:  What should be the goals of treatment?

Dr Kumar:  The goal of treatment of tardive dyskinesia should be to reduce the severity so it doesn't have a significant impact.

The goal is not to necessarily get rid of all the abnormal movements but improve them so the patient is not embarrassed, doesn't affect socialization, doesn't affect their work, doesn't affect activities of daily living, makes it so they don't bite their tongue or the inside of their mouth.

If you over-treat the individual and you get rid of all the abnormal movement, with, for example, an approved VMAT2 inhibitor, there's a chance you may over-treat the patient. You're more likely to cause car side effects, such as drug-induced Parkinsonism. Reduce the severity of the movements so the impact is no longer troublesome.

Ms Thistle:  What should you do if a patient doesn't respond to treatment?

Dr Kumar:  First of all, if a patient doesn't respond to treatment, you should reevaluate the diagnosis. Maybe the patient actually has jaw tremor due to drug-induced Parkinsonism. Maybe the patient has drug-induced tremor caused by their lithium or valproate. Perhaps the patient has another neurologic disorder.

In this situation, reevaluate the diagnosis. In some cases, it may be helpful to have the patient seen by a movement disorder specialist. In some cases, you might want to think about maybe the patient needs a higher dose of the medication.

Have you titrated the dose effectively? If you have, perhaps the patient may be one of those individuals who responds to one of the approved medications and doesn't respond to the other. Consider a switch from one medication to the other. Those are all therapeutic options.

If you still have a refractory patient, consider referral, again, to a sub-specialist in movement disorders who can both reevaluate the diagnosis and look at maybe, perhaps, more advanced therapeutic options. Such as if the patient has dystonic elements for their face or jaw, for example, botulinum toxin injections could be helpful.

If they have more severe, widespread, disabling tardive dyskinesia, in those cases deep brain stimulation should be considered. Again, both botulinum toxin injections for tardive dyskinesia and deep brain stimulation would be off-label but very effective and appropriate therapies in the right clinical scenario.

Rajeev Kumar, MD, FRCPC, is the medical director of the Rocky Mountain Movement Disorders Center and the HDSA Center of Excellence and NPF Care Center at the Colorado Neurological Institute. Dr Kumar is a movement disorders neurologist who attended medical school at the University of Saskatchewan in Canada. He completed his residency at Mayo Clinic and fellowship at the University of Toronto.

Presentation(s):
Live - Tardive Dyskinesia Across the Complexity Spectrum – From Quality of Life Improvement to Novel Treatments