Tardive Dyskinesia Treatment With VMAT2 Inhibitors Doesn't Need to Alter Antipsychotic Therapy

(Part 2 of 2)

Carmen Kosicek, MSN, APNP, PMHNP-BC, explains best practices for implementing VMAT2 therapy while a patient is on antipsychotics as well as her concerns with the use of anticholinergics for tardive dyskinesia (TD) treatment. She also discusses the evidence base for long-term use of VMAT2 inhibitors in patients with TD.

In this podcast, Dr Kosicek answers questions from the audience in a recent Psych Congress Regionals virtual Q&A session moderated by Rakesh Jain, MD, MPH, following her session titled “TD360 2021: Tardive Dyskinesia Across the Complexity Spectrum – From Quality of Life Improvement to Novel Treatments” that she co-presented with Rajeev Kumar, MD.

In the previous part 1, Dr Kosicek discusses insurance coverage of VMAT2 therapies for tardive dyskinesia and the usefulness of documenting an abnormal involuntary movement scale (AIMS) score.

Read the transcript:

Dr Jain: Welcome back everyone. Our next question I have is, What changes do I need to make with the antipsychotic therapy in order to start VMAT2 therapy?

Dr Kosicek:  Great question again. You have a good audience here today.

Dr Jain:  We do.

Dr Kosicek:  Technically, you do not have to change the antipsychotic. I would look into that a little bit further. Make sure that they're on the right med. Is it really the best medication? Is it truly helping with their symptoms?

If they are stable on the medication, there's no need to change it. I would give you a heads-up that it could be possible that they're on too high of a medication because historically, the more that you push down on dopamine, so the higher the dose of the antipsychotic, the more it would impede movement by turning that human being down.

Just make sure that they're really at the optimal dose that they need to be at. It could be they're on a little too heavy of a dose.

In theory, you do not need to change the med. It is no longer thought of as that was the offending agent that you have to move them from. It was truly from anything that affected dopamine.

Dr Jain:  This is really good news, isn't it? We no longer have to harm people to help them. We can now help people and help them, right?

Dr Kosicek:  Absolutely.

Dr Jain:  You're right about great questions. We only have a minute and a half left, Carmen, so help us with these two questions. What is the evidence base for the long-term use of the VMAT2 inhibitors?

Dr Kosicek:  It's actually very solid. You can go to the drug name dot com -- There's two VMAT2 inhibitors. You'll see under the healthcare professional tabs all of the clinical trials that they have. Usually, they additionally have the extension trials.

What they continue to showcase is the longer that they're on a VMAT2, the score of AMES continues to decrease. Not as substantially as in the beginning, but it still has shown over time to continue to diminish.

Dr Jain:  Long-term use is acceptable. In fact, most often indicated, is it not?

Dr Kosicek:  Correct, because if you go off of the VMAT2, the movements will return. No different than if you went off your medication for schizophrenia. Your symptoms will return.

Dr Jain:  I saw, based on the data, you and Dr. Kumar showed no rebound but return of symptoms. That's really good to know.

Thirty seconds, but this is so important let's not skip this one. Anticholinergics, what are your concerns? Why are you so concerned about the use of these medications in Tardive dyskinesia?

Dr Kosicek:  I would sum it up for this bullet point. Evidence-based practice. Actually, know when you read the package insert that medications such as benztropine, Cogentin, they're indirectly increasing dopamine while most commonly you have an antipsychotic to bring dopamine down.

You think of a war going on in the brain. That's before we talk about how they challenge your memory. They dry you out. These are no longer considered the correct medications.

Dr Jain:  Got it. Watch out for anticholinergics, but if you do need them, for example, a patient has comorbid Parkinsonian symptoms and TD, I think that's OK to use together. Right, Carmen?

Dr Kosicek:  That's exactly where it is appropriate, yes.

Interviewer:  Perfect. This was a very good Q&A. In six minutes, you covered literally the most important topics in the world of tardive dyskinesia. Much gratitude to you, Carmen, and much gratitude to my colleagues for being with us for this TD 360 presentation.

Kosicek C, Rajeev K, Jain R. TD360 2021: Tardive Dyskinesia Across the Complexity Spectrum – From Quality of Life Improvement to Novel Treatments Q&A. Presented at: Psych Congress Regionals; July 16–17, 2021; Virtual.