When Monotherapy Doesn’t Work: Treatment Resistance in Tardive Dyskinesia

In this video, Psych Congress Faculty Member Kristian Dambrino, DNP, PMHNP-BC, dives into the nuances of prescribing vesicular monoamine transporter 2 (VMAT-2) inhibitors for the long-term management of tardive dyskinesia (TD). Dambrino discusses topics from her Psych Congress Elevate session that covered the importance of educating patients on the treatment’s potential side effects, her approach to treatment for patients who do not respond to a monotherapy, and the role of individualized treatment plans in meeting patient needs.

For more expert insights on the disorder, visit the Tardive Dyskinesia Excellence Forum.

Read the Transcript

Kristian Dambrino, DNP, PMHNP-BC: Hey, my name is Kristian Dambrino. I'm a psychiatric nurse practitioner living and working in Nashville, Tennessee. I have my own practice, Dambrino Consulting and Wellness.

Psych Congress Network: What does the long-term data on VMAT-2 inhibitors show about sustained symptom control in TD and how does that impact your approach to chronic management? 

Dambrino: With VMAT-2 inhibitors, we do have data that supports long-term efficacy. What we do know about tardive dyskinesia is actually even more important, and that is that TD is typically chronic and irreversible, and it happens as a medication-induced side effect.

This is why it's so important to teach our patients about the repercussions of prescribing dopamine receptor blocking agents and what that impact can be, particularly long-term involuntary movements. When I have that conversation with patients, it really has an impact. It's so important that they understand that can be irreversible.

When I am working with patients, I always know that each patient is different, so the way that they're going to respond to a medication, no matter what the data is, is going to vary among individuals. I always make sure that I'm clear with that. I'm very transparent in my communication with my patients so that we know what to expect. But per the data, it is expected that if there is an improvement or a therapeutic response with a VMAT-2 inhibitor, that should be sustained. 

Psych Congress Network: Given the variability in patient response to TD treatments, how do you approach dosing adjustments and combination of therapies, particularly in patients who may not full respond to a monotherapy?

Dambrino: It is important to remember that not every patient is going to respond to medications we prescribe, particularly with tardive dyskinesia. Because it is chronic and most of the time irreversible, we do need to think about your treatment, which is only as good as your diagnosis. As clinicians, we need to make sure we know what we're looking at. This is why education is very important. We need to be able to, for example, differentiate drug-induced Parkinsonian symptoms from tardive dyskinesia, because if we are prescribing something for drug-induced Parkinsonian symptoms, we can worsen tardive dyskinesia. If we're prescribing a VMAT-2 inhibitor for what we think is tardive dyskinesia and it's not, and it's drug-induced Parkinsonism, we can actually worsen those symptoms. It's very important that we understand what we're doing.

Now, in some cases, patients may not fully respond to a VMAT-2 inhibitor, and they do have tardive dyskinesia. In those cases, I would say, we're always going to treat people individually because sometimes a little improvement is worth that. Let's say someone has a 1-point improvement on the Abnormal Involuntary Movement Scale (AIMS). The AIMS isn't linear. A person with an AIMS of 4 here may look different than another person who has a score of 4 because it's based on different areas in the body. An improvement of 1 point could be the difference in someone being able to hold a coffee cup, for example. This is really important when we're looking at activities of daily living and the lived experience of someone with tardive dyskinesia.

Kristian Dambrino, DNP, PMHNP-BC, is a board-certified psychiatric mental health nurse practitioner and the founder of Dambrino Wellness, an outpatient mental health practice in Nashville, TN. She is pursuing her Doctor of Nursing Practice at Belmont University College of Nursing, with a current focus on innovative global nursing partnerships in Indonesia. Having worked extensively with severe and persistent mental illness in community mental health and crisis settings, Dambrino embraces a trauma-informed, evidence-based prescribing model for her patients.