Treating Tardive Dyskinesia With Patient's Individual Needs and Age in Mind

Craig Chepke, MD, FAPA, medical director of Excel Psychiatric Associates, Huntersville, North Carolina, shares why it is important to try both FDA approved vesicular monoamine transporter (VMAT) 2 inhibitors to treat Tardive Dyskinesia (TD). He also explores how to treat patients with TD who are over 60 years old and at increased risk for the disorder.

Dr Chepke, who is also a Psych Congress steering committee member, answered these questions and more in a recent live Q&A session moderated by Rakesh Jain, MD, MPH, at the virtual Psych Congress Regionals.

For more information on Psych Congress Regionals, visit the meeting website.

Dr Craig Chepke, MD, FAPA, is a board-certified psychiatrist and a Fellow of the American Psychiatric Association. He attended NYU School of Medicine and completed his residency training at Duke University. Dr Chepke is the medical director of Excel Psychiatric Associates in Huntersville, North Carolina, and a clinical assistant professor of psychiatry at SUNY Upstate Medical University and an adjunct associate professor of psychiatry for Atrium Health. He is a member of the Huntington Study Group and serves on the board of directors for the CURESZ foundation, a nonprofit organization dedicated to improving the lives of people living with schizophrenia.

Read the transcript:

Dr Rakesh Jain:

Well, Dr Chepke, it's so nice to have you with us, and what a great session we had on tardive dyskinesia. We've got lots of great questions from our attendees, so let's go ahead and get started. You talked quite eloquently during your [Psych Congress Regionals] presentation about both of the FDA-approved VMAT2 inhibitors.

A colleague is asking us: “What if a patient fails one of these 2 FDA-approved VMAT2 inhibitors? Is it even worth trying the second one, and why should I even give that a try?”

Dr Craig Chepke:

Oh, it absolutely is. I'm so grateful that we do have 2 options, and that they are meaningfully different. They have different drug metabolisms, and they have different ratios of the isomers. It's something that's a little complicated; we didn't get into it in this presentation, but there are different active metabolites that each one of the 2 VMAT2 inhibitors has, and they're different between the 2.

So, there's very good reason to believe that if one does not work, that the other one has a great chance of working. Definitely do not give up on people after only trying one of the 2 FDA per VMAT2 inhibitors. Always, if that one doesn't work, whether for efficacy or for tolerability, give the other one a shot 100 times out of 100.

Dr Jain:

“100 times out of 100.” So, sounds like there are enough pharmacokinetic and pharmacodynamic differences there, and clinicians are to exploit those differences if a patient doesn't respond to one or the other. I've got it.

Dr  Chepke:

Yeah, absolutely. I'm just so grateful that we do have both options. In my clinic, I've fortunately been able to help everyone that I've come across and diagnosed with TD with 1 out of the 2. If we only had one, then some people would've been left out in the cold. So, thank goodness we have 2 good options.
Dr Jain:

I really like the positive way you're looking at it, which is 2 is actually better than one, because people have individual needs. We have time for 1 final question, sir, and that has to do with patients who are over 60 [years old] and who have tardive dyskinesia. 

“Is there anything specific about patients over 60 in terms of making a diagnosis or treatment that you do differently than a patient who's under 60?”

Dr Chepke:

The main thing is just remembering that people that are 60 and over do have an increased risk. Once they do get TD, then you just may have to be careful that they may have some other comorbidities, may have lots of different other medications that are on board, so you got to watch out for drug interactions in that case. They could also be more vulnerable to drug-induced Parkinsonism as well.

So, you want to be cautious, as you’re treating with any VMAT2 inhibitor, that there is a risk of drug-induced Parkinsonism by the mechanism of it reducing the presynaptic dopamine release. Just be on the look after that and keep assessing that as you're assessing the changes in the movements due to the VMAT2 inhibitor treatment. But overall, you do pretty much the same.

There are, again, some data that didn't make it into this particular presentation but is out there that both of the 2 FDA approved VMAT2 inhibitors have done post hoc analyses where they did data cuts of people under and above. It was actually 55 in that particular data cut, but older and younger patients in terms of efficacy and in safety tolerability equivalent. So, they worked as well and were safe and well tolerated in people over 55 as they were under 55.

Dr Jain:

That's very good to know. In other words, just because you are a little bit older, 55, 65, 70, 75, 80. We even have data up to that [crosstalk]...

Dr Chepke:
Yeah, there are data out there. I meant to say [what’s] been published in peer review journals is the lower age. But yes, there definitely are. Have been posters presented, and there are data on even higher age limits and showing similar things that the older age people still get great benefit and have very good tolerability with both of the 2 drugs.

Dr Jain:

That's very positive news. That's really positive news. Dr Chepke, though we only spend about 5 minutes together, you did a great job covering some of the most important things, so thank you very much.

So with that, folks, in addition to thanking Dr Chepke, let's just remember the plight of our patients with tardive dyskinesia and do our very best to address them. See you very soon.