Preventing, Recognizing, and Treating Tardive Dyskinesia in Patients Taking Antipsychotics

Before valbenazine and deutetrabenazine, methods such as low-dosing and screening tools were recommended to prevent tardive dyskinesia (TD) in patients taking antipsychotics. What does prevention-based TD treatment look like with these FDA-approved medications as an option? Is this type of treatment necessary? What should clinicians do should TD develop in their patient? Alan David Kaye, PhD, DABA, DABPM, DABIPP, FASA, and Elyse Cornett Bradley, PhD, RYT, professor and assistant professor, respectively, in the Department of Anesthesiology at Louisiana State University (LSU), New Orleans, answer these questions and more in this interview with Psych Congress Network.

Editor’s Note: This interview has been lightly edited for length and clarity.

Meagan Thistle, Managing Editor, Psych Congress Network: In your experience, is tardive dyskinesia (TD) underdiagnosed? If so, why?
Alan David Kaye, MD, PhD, DABA, DABPM, DABIPP, FASA, and Elyse Cornett Bradley, PhD, RYT: TD is a relatively common condition and side effect of numerous drugs, including antipsychotics. There are delays in diagnosing the condition, this is probably related to limited awareness from patients and clinicians.

Thistle, PCN: How can clinicians treating patients with antipsychotics integrate prevention-based treatment into their practice, if at all?
Dr Kaye and Dr Bradley: Newer antipsychotics are associated with a lower incidence of TD. Therefore, the choice of medications is directly related to the likelihood of developing TD.

Thistle, PCN: How can providers reassess their patient’s treatment course should TD symptoms develop?
Dr Kaye and Dr Bradley: Clinicians should review the medications that they are taking and consider treatment options, including newer agents that are available such as Branched-Chain Amino Acids (BCAAs) and the 2 treatments for TD, which have been approved by the FDA and have Level A evidence, valbenazine and deutetrabenazine. 

Thistle, PCN: How can these 2 FDA-approved drugs be integrated into treatment should prevention-based methods fail?
Dr Kaye and Dr Bradley: Several medications and supplement options are available to ameliorate TD effects. One of the most promising options is Branched-Chain Amino Acids (BCAAs) which appear to improve TD symptoms even for patients taking APDs. While BCAAs may not work for all patients with TD, they are inexpensive and easily acquired, making them an attractive approach to combat TD. Some evidence suggests that an inability to clear ingested forms of the amino acid phenylalanine is associated with TD.

Thistle, PCN: Now that these FDA-approved medications are a treatment option, is prevention-based treatment less of a concern? Why or why not? 
Dr Kaye and Dr Bradley: Prevention is still important as is, of course, early recognition. I think early recognition, careful review of medications, and utilization of these treatments are all important with regard to TD.
Deuterobenzene (Austedo), which works in parts of the brain related to the involuntary movements of TD, is FDA-approved to treat TD in adults and treats movements in the face, tongue, or other body parts that can’t be controlled. Deuterobenzene is a deuterated form of tetrabenazine and is a vesicular monoamine transporter 2 (VMAT2) inhibitor.

Valbenazine (INGREZZA)'s mechanism of action is through the reversible inhibition of VMAT2.

Thistle, PCN: Is there anything else you would like to share with our audience of mental health clinicians?

Dr Kaye and Dr Bradley: A better understanding of conditions such as TD has paved the way for newer and more effective treatments. Clinicians should appreciate how these treatments can impact and improve their patients' conditions, such as TD.

Alan David Kaye, MD, PhD, is a professor within the Department of Anesthesiology at LSU Health Shreveport and also serves as a professor within the Department of Pharmacology, Toxicology, and Neurosciences.  Prior to his arrival in Nov, 2019, Dr Kaye served for 15 years as Professor, Program Director, and Chairman of the Department of Anesthesiology at LSU Health in New Orleans. Before LSU Health Shreveport, he was professor, program director, and chairman for 6 years of the Texas Tech University Health Sciences Center Department of Anesthesiology in Lubbock, Texas. Prior, he was the medical Director of the Greater New Orleans Surgical Center, the Director of Resident Recruitment, program director, and an attending staff of the Department of Anesthesiology at Tulane University Medical Center in New Orleans. Dr Kaye received 2 BS degrees and an MD degree from the University of Arizona. Dr Kaye completed his PhD in pharmacology in May 1997. He has authored or co-authored over 200 abstracts, 800 manuscripts, and 250 book chapters in the fields of pharmacology, pain medicine, and anesthesiology. He is editor-in-chief of the journals Pain Physician and Current Pain and Headache Reports, and is on the FDA Advisory Board on Anesthetics and Analgesics. He was previously an Associate National Board Examiner in Anesthesiology.

Elyse Cornett Bradley, PhD, RYT received her bachelor’s degree in Psychology, Biology, and Chemistry from Western Michigan University, and her doctoral degree in Pharmacology, Toxicology and Neuroscience from LSU Health Shreveport. She also trained at the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH) Dr Bradley teaches medical and graduate students, residents, faculty, scientists, and fellows in all medical specialties and disciplines how to write and publish medical articles through the LSU Medical Science Writing Distinction Program which fosters inter-departmental collaborations of research and writing development at LSU Health Shreveport. She also teaches basic pharmacology, behavioral neuroscience, and clinical neuroscience courses. Her academic work includes over 200 peer-reviewed PubMed-indexed publications, over 100 textbook chapter publications, and serving as editor of several books.