tardive dyskinesia

Etiology

• late complication of antipsychotic therapy or treatment with dopamine receptor antagonist (haloperidol, chlorpromazine, thiothixine))
  • generally noted after > 5 years of antipsychotic therapy
  • isolated incidences after 1-3 months have been reported
  • first generation antipsychotics with highest risk
• anti-emetics:
  • metoclopramide
  • prochlorperazine
• antidepressants
  • risk associated with SSRI & tricyclic antidepressants much lower than with antipsychotics
  • phenelzine, trazodone
• anticonvulsants
  • carbamazepine, ethosuximide, phenobarbital, phenytoin
• levodopa, bromocryptine
• amisulpride
• lithium carbonate
• estrogens
• amphetamine, methylphenidate
• longstanding psychosis
• idiopathic on some elderly individuals, especially if edentulous

Epidemiology

• may be 20-30% with long-term use of antipsychotic

Pathology

• dopamine receptor sensitivity in the basal ganglia

Clinical manifestations

• choreiform & dystonic craniofacial movements
• rhythmic, repetitive, bizarre movements largely involving the face, mouth, jaw & tongue
• grimacing, pursing of the lips, protrusions of the tongue, opening & closing of the mouth, & deviations of the jaw also occur
• the extremities & trunk are less frequently involved
• generally occurs at rest
  • abnormal movements lessen with activation or touch
• the condition is often unrecognized by the patient
• symptoms may take months to resolve of become permanent.

Diagnostic criteria

• neuroleptic-induced tardive dyskinea requires symptoms that persist for 1 month after exposure to neuroleptics for >= 3 months
• at least 1 month of exposure is required if patient is > 60 years

Differential diagnosis

• Wilson's disease
• Huntington disease
• brain lesion

Management

• consider reducing or discontinuing offending antipsychotic agent
  • upon discontinuation of offending agent, symptoms may take months to resolve
  • condition may be permanent
  • dose reduction preferable in the elderly
• switch offending antipsychotic to clozapine (Clozaril)
  • reduce dose of offending agent in elderly prior to switch to clozapine
• VMAT2 inhibitors
  • valbenazine (Ingrezza) FDA-approved 2017 tolerated > 1 year
  • deutetrabenazine (Austedo) also FDA-approved
• dose reduction preferable to VMAT2 inhibitor in the elderly
• clonazepam, 0.25-4 mg per day, is probably effective
• Gingko biloba, 80-240 mg per day, is probably effective
• amantadine is possibly effective

More general terms

• dyskinesia

Patient information

tardive dyskinesia patient information