Tardive Dyskinesia, Comorbidities and Treatment Options

Rakesh Jain, MD, MPH, Psych Congress steering committee member, clinical professor, Department of Psychiatry, Texas Tech University School of Medicine, Austin, Texas guides a 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."

Read the Transcript:

Dr Rakesh Jain:  Folks, this is the Psych Congress way of perhaps looking at all disorders. We start with the patient, and then we backtrack to understanding the science, look at the mistakes we've made, and try not to repeat them.

Thank you both. You guys are absolutely remarkable in educating us. We will not forget the lessons you taught us. We have lots of questions. Five and a half minutes, 30 seconds each. If you will, please, question number one.

How would you treat a patient with both drug-induced Parkinsonism and TD? I will start with you, Dr Kumar.

Dr Rajeev Kumar:  This can occur. This is actually our next case. I didn't think we'd have enough time for this, but we might. OK, so, here we go. They can co-occur. Let's see some examples here. It can occur. It can be difficult to treat.

We see this guy. He's got lip and tongue choreic movements. He's going to show, you're going to show, that he's got resting tremor in his hand, and slow rhythmical tremor. It comes out when we see him walk. He's got this puckering movements. He calls it the fish mouth appearance.

He's got a little postural tremor. He's got a little endpoint kinetic tremor. When I do finger tapping, we can see he's a little slow in pronation/supination movements of the hands, and he has worsening of his facial movements.

When we see him walk in a minute, we're going to see he walks a little slowly with reduced arm swing. Dr Meyer, what would be the first approach? This guy's on an atypical antipsychotic and has drug-induced Parkinsonism, but he has Tardive dyskinesia. Go ahead and show the next video while Dr. Meyer speaks.

Dr Jonathan Meyer:  One thing, always, you can make a Parkinsonism better if you can shave down the dose, but sometimes, that's simply not possible. We need to treat some people often after a threshold for Parkinsonism for often control of psychosis.

In that case, amantadine is going to be the way to go, because amantadine can help the Parkinsonism and is not going to make your TD worse. Would you agree with that?

Dr Kumar:  Yeah. What we tried to do is, in this guy's, we were able to actually take him off. He was being treated for refractory depression. Taking him off his antipsychotic, but if he's had a primary psychotic illness, I'd try to move him to clozapine, if I could.

Dr Meyer:  OK, so that's another option, going from a stronger to a weaker D2 blocker, or dose reduction. I'll give both as possibilities, OK.

Dr Kumar:  Then if his TD is still troublesome, then, once we resolve the Parkinsonism, then we treat the TD, right? Amantadine, reduce the D2 blockade, and then treat the Parkinsons, treat the TD with a VMAT2 inhibitor if it's still troublesome.

Dr Meyer:  The idea is anticholinergics are the wrong answer, OK? Wrong answer.

Dr Jain:  Pertinent positives and pertinent negatives in this approach. This is for you, Jonathan, if I may have just a very quick answer from you. What is the evidence base for the long-term use of the VMAT2 inhibitors? You presented that, but a colleague wants reinforcement of that message.

Dr Meyer:  They have data now going out to, I believe...There's been people who've been on tetrabenazine for decades, by the way, but for the newer drugs, at least three-year published data do it, and at least one year for valbenazine.

Very well tolerated, and most importantly, continued improvement, which is very cool.

Dr Jain:  That's wonderful. For you, sir, how do you differentiate Huntington's chorea and Tardive dyskinesia? Can they actually occur together? Will the treatments be different?

Dr Kumar:  That's a tough question. I see lots of HD patients. First of all, family history, genetic testing. Look at eye movements. Eye movements are almost always abnormal in HD, not abnormal in Tardive dyskinesia.

Usually have more distal and limb chorea than facial chorea with HD. That's quick and dirty and quick and easy. Yes, you can have co-occurrence, because you might use antipsychotics for both the psychiatric problems plus chorea control, and it can be a hard problem to treat. VMAT2 inhibitors work for both.

Dr Jain:  Question for you. Any research suggesting that VMAT2 inhibitors could prevent TD, if started at the same time as the antipsychotic medication?

Dr Kumar:  We don't have evidence for that. Again, the majority of people are not going to get TD, so the idea you're going to start something for which 93% on an atypical are never going to get doesn't really make sense, anyhow, but we just don't have evidence of that.

Dr Jain:  It is intriguing, is it not? Can lithium over time cause TD, or it's just only antipsychotics?

Dr Kumar:  Yeah, you need to use a dopamine receptor-blocking medication. It's an antipsychotic or an antiemetic that blocks dopamine receptors, not lithium.

Dr Jain:  Got it, sir. What change do I need to make with the antipsychotic therapy in order to start VMAT2 therapy? The questioner says, "Please don't give me the politically correct answer. Tell me what you actually do."

Dr Kumar:  The correct answer is none. You don't need to change a darn thing, and I encourage you not to. These are well-tolerated in clinical trials. People remained on their antipsychotics and other agents as well. Don't change anything if they are clinically stable from a psychiatric perspective.

Dr Jain:  Got it. Because the question and answer session is so good, I'm just going to keep on rolling. In psychiatry, we use anticholinergics very often. As the neurologist who's consulting with a psychiatrist, what is your specific concern about the use of anticholinergics with TD? Why are you so worried about it?

D. Kumar:  Yeah, so first of all, you're giving a drug which is not very helpful, and it's probably worsening the problem. You're causing other potential side effects, including cognitive impairment. If I want to treat the TD, I want to first of all get rid of aggravating factors.

Then, if it's still troublesome, then I want to use the VMAT2 inhibitor, typically.