Keeping Patient Needs at the Center of Tardive Dyskinesia Treatment

How can clinicians best center patient needs while prescribing treatment for tardive dyskinesia (TD)? In this video, filmed at Psych Congress Elevate 2024, Psych Congress Steering Committee Member Jonathan Meyer, MD, explores TD treatment approaches that can optimize a patient’s overall well-being. Dr Meyer compares the impacts that the 2 Food and Drug Administration (FDA)-approved medications for TD treatment may have on patients. He also assesses what a successful intervention could look like from a patient’s perspective and encourages clinicians to evaluate the progress of their patients’ treatment beyond an Abnormal Involuntary Movement Scale (AIMS) score.

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

For more information and to register for this year’s Psych Congress Elevate taking place May 28th through 31st, visit the meeting website.

Read the Transcript

Jonathan Meyer, MD: Hi out there in Radioland. I'm Dr Jonathan Meyer, voluntary clinical professor of psychiatry at the University of California, San Diego, and a member of the steering committee of Psychiatric Congress.

Psych Congress Network: How can TD treatment approaches be tailored to minimize the impact on the patient's daily life and overall well-being?

Meyer: I think something we've come to appreciate now that we have 2 FDA-approved medications for tardive dyskinesia is that it's not just a movement disorder, it's a disorder of people. And crucial to understanding the person is to understand the specific impact on them. For some individuals, it might be a social impact because of where the movements occur and the type of work that they do.

For others, it may be psychological, often it's both, and of course, there can be a physical functional component as well. 

The idea is that you have to understand what bothers the person as you approach TD treatment. Their goal of treatment may not be an AIMS score, it may be, “I want to be able to go out and not have people notice my movement. I want to be able to do a certain activity, which is difficult because of my movement. I want to be able to chew and eat without having to think about every mouthful, worrying that I might choke.”

I think the take home message is that doing an AIMS is an incomplete assessment of tardive dyskinesia. You have to understand the functional impact. There are new scales which have emerged, one of them is called the Impact-TD scale. Know what that is so you can see as you're using a medication to treat TD if it's getting the desired result from the patient's perspective, not just from your perspective based on the AIMS rating.

PCN: How do different treatment options for TD compare in terms of efficacy and side effects, and what factors should clinicians consider when selecting the most appropriate treatment for their patients?

Meyer: We have 2 strongly evidence-based treatments for tardive dyskinesia. These are the 2 FDA-approved vesicular monoamine transporter 2 (VMAT-2) inhibitors, valbenazine and deutetrabenazine. They're both effective, they're both approved. The effect size for the highest dose of valbenazine, which is 80 mg, is quite high. It has a large effect size at 0.90. For deutetrabenazine, the highest prescribed dose is 48 mg. We don't have an effect size for that because it wasn't studied in a fixed-dose study. We do have an effect size for the next lower dose of 36 mg, and that's in the 0.6 range. 

I think the point is they're both effective, you just have to know how to titrate each one. In the essence of valbenazine, there is no titration. You simply start at 40 mg and on average you go to 80 mg within a week. Tolerability tends to be quite good. We see for valbenazine, at the end of a 6-week study, the dropouts due to adverse effects are almost the same for drug and adjunctive placebo.

Deutetrabenazine has a titration over the first month to the minimum dose of 36 mg. The reason I say “minimum” is that when you look at the long-term studies, the average dose for most people is around 39 mg. So we would say in general 36 should be your initial target goal. And if symptoms persist and the person's perhaps not on a [CYP2D6] inhibitor or [CYP2D6 ] poor metabolizer, then you can pursue higher dosages. 

We do see differential rates of adverse effects. Whether this relates to inherent properties of the drug or the slower titration for deutetrabenazine, it's hard to say for sure, but we see relatively low rates of adverse effects for deutetrabenazine, and again, dropouts compared to placebo are almost exactly the same. So, I think in the end, where you get to one or the other may depend on the patient's insurance, also whether the patient prefers a slower or faster titration. These are really the driving factors as much as anything in choosing to be VMAT-2 inhibitor. 

This is Dr Jonathan Meyer, and I want to thank you again for watching this episode. I hope you learned some insights, which may be helpful to you in your current and future practice, and I encourage you to come back to the site for future updates.

Jonathan Meyer, MD, is a voluntary clinical professor of psychiatry at the University of California, San Diego, and a Distinguished Life Fellow of the American Psychiatric Association. Dr Meyer is a graduate of Stanford University and Harvard Medical School, and finished psychiatry residency and fellowships at LA General Medical Center. Dr Meyer has teaching duties at UC San Diego, is a Senior Academic Advisor to the California Department of State Hospitals, and is a psychopharmacology consultant to the first episode psychosis program at the Balboa Naval Medical Center.