Treating TD: Best Practices for the Use of Antipsychotics, Anticholinergics, and VMAT2 Inhibitors

Carmen Kosicek, MSN, APNP, PMHNP-BC and Rajeev Kumar, MD discuss the use of antipsychotics and anticholinergics in psychiatry, and VMAT2 inhibitors for the treatment of tardive dyskinesia (TD). They explain the side effects and best practices for clinicians creating treatment plans with patients with TD.

Dr Kosicek and Dr Kumar answer questions from the audience in a recent Psych Congress Regionals virtual Q&A session moderated by Rakesh Jain, MD, MPH, following the session titled “TD360 2021: Tardive Dyskinesia Across the Complexity Spectrum – From Quality of Life Improvement to Novel Treatments." 

Read the transcript:

Rakesh Jain, MD:  Welcome back, dear colleagues. We are now going to engage in a wonderful Q&A with both Carmen and Rajeev. Carmen, I'll start with the very first question, if I may, with you. What changes do I need to make with the antipsychotic therapy in order to start a patient VMAT2 therapy? What do you say?

Carmen Kosicek, APRN:  Great question. Overall big picture, you don't need to change the current antipsychotic if they're already stable. Obviously, you should look to see, are they at the lowest efficacious dose, or is the dose too high? It's like with everything, not 100 percent cut and dry, but you do not need to change what they're on to then add on a VMAT2.

Jain:  Got it. Rajeev, what would you add to those words of wisdom?

Rajeev Kumar, MD:  Nothing really. I think that they're ideal. Obviously, if the patient is commonly on an antipsychotic, you'll use the lowest effective dosage. You titrate to efficacy with respect to titrating the VMAT2 inhibitor while keeping the patient primarily psychiatrically stable. That is the goal.

Jain:  Got it. We can do both. Both are achievable. Thank goodness for the two new VMAT2 inhibitors. Carmen, if you could get this ball rolling too, what is the evidence base for long-term use of the two VMAT2 inhibitors you discussed a minute ago?

Kosicek:  Again, the clinical data that you can see on both of the websites, they are long-term, and they continue to showcase a decrease of the negative movements, so a decrease in AIMS. Long term, several years out, these have been studied. They are medications that you should continue to stay on.

Jain:  And the side effect burden did not go up any, Rajeev, is that correct?

Kumar:  No. In fact, most of the adverse effects are seen during the titration period. Once the patient is stabilized, in general, the vast majority of patients do not experience new onset adverse effects. Indeed, over the long haul, you'd have an increase in better benefits, seemingly perhaps from a long-term pharmacodynamic effect of long-term therapy.

Jain:  Then one should keep an eye on it. Patients could certainly develop other conditions. The patient who's getting older could develop Parkinson's disease. One should not just assume the status quo is going to persist. Well said both of you. We have one minute, but we have an incredibly important question.

Carmen, anticholinergics are very often used in psychiatry. Do you have any concerns about that?

Kosicek:  Yes, if you read the package insert, the most commonly used one, benztropine or Cogentin, is actually not recommended at all per the package insert to continue after 14 days of use if there is TD. It can make symptoms worse.

Please be mindful that anticholinergics, indirectly, increase dopamine. If they're on an antipsychotic to bring it down, you now have a war going on in the brain. No longer is that considered current evidence-based practice of something to be utilized long term with movements that are there for TD.

Jain:  Got it. In the last few seconds we have left, Rajeev, what would you say to this very important issue about the use of anticholinergics and patients with TD?

Kumar:  Beyond potentially worsening the TD, of course, deprescribing is the word of the day. Consider deprescribing because there are many other adverse effects, especially beware of cognitive adverse effects. Our psychotropics tend to worsen not improve cognition in most patients. The additional central anticholinergics effect will simply worsen that. If you can, try to taper and discontinue for that purpose also.

Jain:  Got it. You heard it, folks. Anticholinergics, extreme caution in all patients, but particularly those with TD. Carmen and Rajeev, we have sadly run out of time, but thank you so much for a really wonderful 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; June 16–18, 2021; Virtual.