Takeaways From Updated Guideline Recommendations for Tardive Dyskinesia Treatment Using VMAT2 Inhibitors

In Part 2 of this Q&A, Craig Chepke, MD, FAPA, adjunct associate professor of Psychiatry for Atrium Health, adjunct assistant professor of psychiatry for The University of North Carolina School of Medicine, Chapel Hill, discusses the key takeaways for clinicians from the updated guideline recommendations for the treatment of tardive dyskinesia (TD) with vesicular monoamine transporter 2 (VMAT2) inhibitors.

In this expansion on his recent Psych Congress Elevate session titled “Tardive Dyskinesia Across the Complexity Spectrum – From Quality of Life Improvement to Novel Treatments," Dr Chepke also explains misconceptions in this area including how effective anticholinergics are in the treatment of TD.

In the previous Part 1, Dr Chepke who is also the Medical Director of Excel Psychiatric Associates, Huntersville, North Carolina, explains how clinicians should be vigilant about screening patients for TD as earlier detection is key in improving or slowing illness severity.

Q: What are the key takeaways for clinicians from the updated guideline recommendations for treatment with vesicular monoamine transporter 2 (VMAT2) inhibitors?

Dr Chepke: The recent guideline updates the call for us to step up the frequency of monitoring for TD. Structured exams like the AIMS on an annual or semiannual basis aren’t enough. We should be conducting brief, semistructured exams on every patient at every visit. But even though conducting the AIMS is important, we need to rethink how we interpret the scoring. Historically, we’ve judged the severity of TD by the sum of the scores of AIMS items 1 through 7, but there is no score on any rating scale that can tell us if a patients’ TD is mild, moderate, or severe. As such, we should decide who to treat with a VMAT2 inhibitor based on the impact on the patient’s quality of life, not an arbitrary threshold on the AIMS 1 through 7 total score. The choice of additional pharmacological agents to treat TD used to be seriously murky, but no longer. Since the approval of deutetrabenazine and valbenazine for TD in 2017, the guidelines have clearly converged on using these two VMAT2 inhibitors as first-line treatments for TD. Every patient with distress or impairment from TD should be offered a trial with an approved VMAT2 inhibitor.

Q: Are there any misconceptions on this topic that you would like to clear up?

A: The first misconception is that anticholinergics can help treat TD. Even though the prescribing information for benztropine warns against it 3 times, I still hear from clinicians that they consider benztropine a possible treatment for TD. However, the one that bothers me the most is the belief that people with TD “don’t notice” or “aren’t bothered” by it. While this may be the case for some, I’ve found that when I ask patients specific questions about how TD may affect their life across the biopsychosocial spectrum, nearly every one of them has identified ways it negatively impacts their quality of life. They just had never been given the information they needed to be able to connect the dots of cause and effect. However, they shouldn’t have to make those links themselves. As clinicians, we are the ones with the education and the training, so that’s our job.

Q: Any final thoughts on this topic?

A: No matter what setting one practices in, if you prescribe antipsychotics, you have patients under your care that have TD. whether or not you’ve identified them. It’s our duty to find and correctly diagnose every one of them. People with undiagnosed TD live with physical, social, and emotional impairments. Now that there are 2 efficacious and well-tolerated VMAT2 inhibitors that are approved to treat TD, it is an unnecessary burden for most of them. Take this quote about drug-induced movement disorders from one of my heroes, Professor David Cunningham Owens, as a call to arms: “The rule of thumb in psychiatric practice should be to always assume the presence of such features, never their absence. One should not wait for them to emerge but anticipate their appearance, nor allow them to lurk in dark corners unheeded, but from their start hunt them out.”

Craig Chepke, M.D., FAPA, is an Adjunct Associate Professor of Psychiatry for Atrium Health, an Adjunct Assistant Professor of Psychiatry for The University of North Carolina School of Medicine, Chapel Hill, and the Medical Director of Excel Psychiatric Associates, Huntersville, North Carolina.