TD: Commonly impairing, often untreated1,2
~785,000 Americans live with the symptoms of TD, but only ~15% of patients are formally diagnosed and ~5% receive appropriate treatment.2
In IMPACT-TD, the largest
tardive dyskinesia (TD) study to date…
of patients were negatively impacted in
some aspect of
daily living 1,2
- Despite living with involuntary movements for a median of 5.5 years, more than half of patients in IMPACT-TD remained undiagnosed at the time of the study 2
- Patients without a formal diagnosis were more often younger, male, Black and/or Hispanic, and had an underlying psychotic disorder 2
Over half of individuals with mild TD experience moderate-to-severe impact1
Severity of impact“I became more of an introvert, accommodating for my TD. I had gotten to a point where communication was almost impossible for me because I was so self-conscious about the movements.”
A majority of patients experienced impact across multiple domains of daily living2
Social interactions
Daily functioning
Communication
Sleep
Self-esteem
Any TD symptoms that impact patients should be treated3
- 3-year, prospective, non-interventional, Phase 4 study evaluating how TD progresses over time and the impact it has on patients’ lives
- Most recent analysis included 286 adult patients either with probable TD (defined as a score of 2 or greater on at least 1 AIMS item) or taking a VMAT2 inhibitor
- Study includes a broad representation of people affected by TD (age, sex, race/ethnicity, underlying conditions, movement severity, and treatment status)
- Baseline data on multidimensional impact of TD were measured using the IMPACT-TD clinician scale and the IMPACT-TD PRO patient-reported scale*
*The IMPACT-TD clinician scale is a newly developed clinician-reported outcome tool used to assess the multidimensional impact of TD on patients’ lives. The IMPACT-TD PRO scale was developed using patient and caregiver feedback, and assesses patient-reported physical and psychosocial impact of TD using a 5-point Likert scale. IMPACT-TD scales were developed by a Teva-sponsored consensus panel composed of clinical and research experts.1,4
See a real patient’s story: the daily impact of TD
Hear a nurse practitioner with TD talk about its impact
For more videos, visit the YouTube page.
Onscreen text:
FROM DIAGNOSIS TO MOVEMENT IMPROVEMENT
DENISE’S TD STORY
Denise, FNP
Primary conditions: bipolar disorder, depression, anxiety, ADHD
Disclaimer on bottom of screen:
This was an individual patient’s experience. Results may vary.
ADHD, attention- deficit/hyperactivity disorder; TD, tardive dyskinesia.
Denise:
My name is Denise. I’m a Family Nurse Practitioner.
I see mental health patients. I see diabetes, hypertension, chronic kidney disease, all kinds of chronic disorders.
The most important thing about my job that I love is talking to my patients and communicating with them and getting to know them.
Onscreen text:
Denise had been taking antipsychotic medications for several years when she noticed involuntary movements in her jaw, hands, and feet—and so did her colleagues and patients.
Denise:
Gradually things just continued to get worse.
That feeling very much did affect my overall mental health. Most of my life was lived in a depression.
And I did worry about whether or not I'd be able to continue my work because it became harder and harder just to get through the day. And I didn't want to talk to people, and I didn't want to really do my job anymore.
Seeing patients became more of a duty instead of a passion anymore, because I was just trying to get through the day instead of taking time to acknowledge my patients.
Onscreen text:
Denise went 5 years without proper diagnosis or treatment while her movements continued to impact her daily activities...
…until her PCP recognized her movements as TD during a routine visit.
Disclaimer on bottom of screen:
PCP, primary care physician.
Denise:
The diagnosis of TD was more of a relief, because I knew that I had been mistreated the whole time and misdiagnosed for so long that when somebody said, "You actually have TD," it was like, maybe we can start over and actually get some treatment that works.
Onscreen Indication and Black Box Warning:
AUSTEDO XR® and AUSTEDO® are indicated in adults for the treatment of tardive dyskinesia and for the treatment of chorea associated with Huntington's disease.
IMPORTANT SAFETY INFORMATION
Depression and Suicidality in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO can increase the risk of depression and suicidal thoughts and behavior (suicidality) in patients with Huntington’s disease. Balance the risks of depression and suicidality with the clinical need for treatment of chorea. Closely monitor patients for the emergence or worsening of depression, suicidality, or unusual changes in behavior. Inform patients, their caregivers, and families of the risk of depression and suicidality and instruct them to report behaviors of concern promptly to the treating physician. Exercise caution when treating patients with a history of depression or prior suicide attempts or ideation. AUSTEDO XR and AUSTEDO are contraindicated in patients who are suicidal, and in patients with untreated or inadequately treated depression. Please see additional Important Safety Information at the end of this video.
Denise:
…As I started taking AUSTEDO XR, I noticed that within a couple of weeks that my feet…weren’t moving around everywhere. And then my jaw stopped moving as much…my speech returned to normal.
I'm on five different mental health medications to control my disorders. I didn't have to alter any of them.
…As I was being treated for my TD, my movements improved…my day-to-day life improved.
Onscreen text:
Thanks to accurate diagnosis and VMAT2 inhibitor education, Denise had finally found effective and tolerable TD treatment.
Disclaimer on bottom of screen:
Patient was compensated for her participation.
Onscreen text:
Learn more about how the right diagnosis—and the appropriate treatment—can make a difference for your patients like Denise at AUSTEDOhcp.com.
Onscreen ISI scroll:
INDICATIONS AND USAGE
AUSTEDO XR and AUSTEDO are indicated in adults for the treatment of tardive dyskinesia and for the treatment of chorea associated with Huntington's disease.
IMPORTANT SAFETY INFORMATION
Depression and Suicidality in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO can increase the risk of depression and suicidal thoughts and behavior (suicidality) in patients with Huntington’s disease. Balance the risks of depression and suicidality with the clinical need for treatment of chorea. Closely monitor patients for the emergence or worsening of depression, suicidality, or unusual changes in behavior. Inform patients, their caregivers, and families of the risk of depression and suicidality and instruct them to report behaviors of concern promptly to the treating physician. Exercise caution when treating patients with a history of depression or prior suicide attempts or ideation. AUSTEDO XR and AUSTEDO are contraindicated in patients who are suicidal, and in patients with untreated or inadequately treated depression.
Contraindications: AUSTEDO XR and AUSTEDO are contraindicated in patients with Huntington’s disease who are suicidal, or have untreated or inadequately treated depression. AUSTEDO XR and AUSTEDO are also contraindicated in: patients with hepatic impairment; patients taking reserpine or within 20 days of discontinuing reserpine; patients taking monoamine oxidase inhibitors (MAOIs), or within 14 days of discontinuing MAOI therapy; and patients taking tetrabenazine or valbenazine.
Clinical Worsening and Adverse Events in Patients with Huntington’s Disease: AUSTEDO XR and AUSTEDO may cause a worsening in mood, cognition, rigidity, and functional capacity. Prescribers should periodically re-evaluate the need for AUSTEDO XR or AUSTEDO in their patients by assessing the effect on chorea and possible adverse effects.
QTc Prolongation: AUSTEDO XR and AUSTEDO may prolong the QT interval, but the degree of QT prolongation is not clinically significant when AUSTEDO XR or AUSTEDO is administered within the recommended dosage range. AUSTEDO XR and AUSTEDO should be avoided in patients with congenital long QT syndrome and in patients with a history of cardiac arrhythmias.
Neuroleptic Malignant Syndrome (NMS), a potentially fatal symptom complex reported in association with drugs that reduce dopaminergic transmission, has been observed in patients receiving tetrabenazine. The risk may be increased by concomitant use of dopamine antagonists or antipsychotics. The management of NMS should include immediate discontinuation of AUSTEDO XR and AUSTEDO; intensive symptomatic treatment and medical monitoring; and treatment of any concomitant serious medical problems.
Akathisia, Agitation, and Restlessness: AUSTEDO XR and AUSTEDO may increase the risk of akathisia, agitation, and restlessness. The risk of akathisia may be increased by concomitant use of dopamine antagonists or antipsychotics. If a patient develops akathisia, the AUSTEDO XR or AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.
Parkinsonism: AUSTEDO XR and AUSTEDO may cause parkinsonism in patients with Huntington’s disease or tardive dyskinesia. Parkinsonism has also been observed with other VMAT2 inhibitors. The risk of parkinsonism may be increased by concomitant use of dopamine antagonists or antipsychotics. If a patient develops parkinsonism, the AUSTEDO XR or AUSTEDO dose should be reduced; some patients may require discontinuation of therapy.
Sedation and Somnolence: Sedation is a common dose-limiting adverse reaction of AUSTEDO XR and AUSTEDO. Patients should not perform activities requiring mental alertness, such as operating a motor vehicle or hazardous machinery, until they are on a maintenance dose of AUSTEDO XR or AUSTEDO and know how the drug affects them. Concomitant use of alcohol or other sedating drugs may have additive effects and worsen sedation and somnolence.
Hyperprolactinemia: Tetrabenazine elevates serum prolactin concentrations in humans. If there is a clinical suspicion of symptomatic hyperprolactinemia, appropriate laboratory testing should be done and consideration should be given to discontinuation of AUSTEDO XR and AUSTEDO.
Binding to Melanin-Containing Tissues: Deutetrabenazine or its metabolites bind to melanin-containing tissues and could accumulate in these tissues over time. Prescribers should be aware of the possibility of long-term ophthalmologic effects.
Common Adverse Reactions: The most common adverse reactions for AUSTEDO (>8% and greater than placebo) in a controlled clinical study in patients with Huntington’s disease were somnolence, diarrhea, dry mouth, and fatigue. The most common adverse reactions for AUSTEDO (4% and greater than placebo) in controlled clinical studies in patients with tardive dyskinesia were nasopharyngitis and insomnia. Adverse reactions with AUSTEDO XR extended-release tablets are expected to be similar to AUSTEDO tablets.
Please see full Prescribing Information, including Boxed Warning, at AUSTEDOhcp.com.
Anyone in the office can use this tool to help assess and identify patients’ involuntary movements
TD symptoms can disrupt the treatment of your patient’s underlying condition5,6
In a separate survey of 269 patients with TD, involuntary movements interfered with adherence to psychiatric treatment5:
48.4%
Skipped doses of antipsychotic medication or took less than
doctor instructed
39.3%
Stopped taking antipsychotic medication altogether
35.7%
Stopped going to the doctor to treat their underlying condition
20.8%
Advised someone else not to take an antipsychotic medication
Real-world survey assessing the impact of TD on treatment of patients’ underlying psychiatric conditions5
- Survey included patients with major depressive disorder, schizophrenia or schizoaffective disorder, and bipolar disorder
- Patients’ TD symptoms ranged from mild to very severe
- Patient population spanned a diverse range of races/ethnicities
No clinical trials have been conducted to suggest that treating TD affects the outcomes presented on this page.
Watch Amber Hoberg, PMHNP-BC, discuss the importance of assessing and managing TD
For more videos, visit the YouTube page.
Voiceover:
Welcome to TD Talks and today’s installment: The need to assess and manage tardive dyskinesia, or TD.
Amber Hoberg:
Hi, I’m Amber Hoberg. I’ve been a psychiatric nurse practitioner treating people with TD for more than 10 years.
As a known complication of antipsychotic drugs, TD affects about 500,000 patients in the United States.
Yet, many of these patients may not tell us about their symptoms or may minimize the impact that TD is having on their lives. It’s therefore critical that we do not make assumptions and do everything we can to uncover the true impact of TD. That way, we can ensure that patients receive the quality care they need.
So, if patients aren’t complaining about their TD symptoms, why are they still so important to assess and manage?
TD can have a profound impact on everyday life for these patients, including the way it affects their primary condition and treatment with antipsychotic drugs, or APDs. This often manifests in the cycle you see here.
Patients with TD can experience a significantly more severe and refractory course of their primary condition. This can include a poor response to care and an increased risk of relapse or readmission.
In addition, patients have said that involuntary movements affect their physical health and can make everyday activities a challenge.
Despite this, between 20 and 30 percent of patients may not be aware that they are experiencing TD symptoms. It is for these very important reasons that we need to be sure we’re assessing our patients for TD—even if they’re not bringing up the subject themselves.
Whether minor or very apparent, the symptoms of TD can affect every patient, and those who care for them, differently. That is why it is so important not only to talk to the patient, but to also involve the patient’s family or caregivers in your assessment.
For example, I often engage a patient’s spouse or partner to see the impact the symptoms might be having on their everyday lives and relationships at home.
We can start by asking about symptoms across these 3 categories: psychosocial, functional, and physical. These questions can help identify the presence of TD and evaluate the severity of each patient’s symptoms.
To see TD symptoms more clearly, you can ask your patient to perform activation maneuvers, as shown onscreen. Activation maneuvers can help reveal any underlying TD symptoms or highlight symptoms that may initially be less apparent. If any involuntary movements are noted, a thorough workup should be done.
Although asking patients about the impact of symptoms on their life is the first step in our evaluation, it is also important to consider the objective severity of TD symptoms and how they may affect functioning.
Therefore, it is best practice to also use standardized measures such as the AIMS scale. By using the AIMS scale, we have a consistent way to evaluate patients’ TD symptoms and response to management over time.
Remember, it is not just the more severe scores that require further evaluation—any score above zero should trigger a deeper qualitative assessment on how those functions may be affecting their daily life.
AIMS can be performed in both in-person or telehealth settings. However, virtual assessments should be intermixed with live exams when possible.
The APA recommends clinical assessment of abnormal involuntary movements prior to initiating APD therapy and at follow-up visits. The exact frequency of AIMS follow-up is driven by APD history and level of risk.
If assessments are scheduled virtually, there are a few considerations to keep in mind.
Be sure to work out the appropriate camera angle with your patient prior to initiating the exam. I recommend activating your patients by mimicking their maneuvers on your end of the screen—so make sure they can see you, too.
If you cannot see your patient clearly onscreen, you may need to rely on patient commentary or a caregiver’s observation to evaluate certain body locations. If the platform doesn’t work at all, request to switch to a different program so you’re able to view your patient more clearly.
As rigidity cannot be formally assessed remotely, observe the arms while the patient is walking. Absence of arm swing can be a clinical sign of rigidity.
Lastly, be aware of the limitations that may be encountered during the assessment, including the inability to observe lower limbs, midline structures, and upper limbs. Inability to assess rigidity associated with parkinsonism; and technological limitations that may affect the test.
In summary, it’s critical to identify and address TD in order to minimize the effects that it can have on patients’ well-being.
Do so by leveraging established assessment criteria, and ask further questions to reveal the true impact that their symptoms may be having on their life.
Remember, by assessing the impact of TD and managing symptoms, you can make a tremendous difference in a patient’s life.
Thanks for watching this installment of TD Talks.
AIMS, Abnormal Involuntary Movement Scale; TD, tardive dyskinesia; VMAT2, vesicular monoamine transporter 2.
REFERENCES: 1. Finkbeiner S, Konings M, Henegar M, et al. Multidimensional impact of tardive dyskinesia: interim analysis of clinician-reported measures in the IMPACT-TD registry. Poster presented at: Annual Psych Congress Elevate; May 30-June 2, 2024; Las Vegas, NV. 2. Data on file. Parsippany, NJ: Teva Neuroscience, Inc. 3. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Schizophrenia. 3rd ed. American Psychiatric Association; 2021. 4. Finkbeiner S, Konings M, Henegar M, et al. Interim analysis of a patient-reported impact measure in the IMPACT-TD registry. Poster presented at: Annual Psych Congress Elevate; May 30-June 2, 2024; Las Vegas, NV. 5. Jain R, Ayyagari R, King S, Edwards GG, Wilhelm A, Leo S. Impact of tardive dyskinesia on physical, psychological, and social aspects of patient lives: a survey of patients and caregivers in the United States. Poster presented at: Psych Congress 2021; October 29-November 1, 2021; San Antonio, TX. 6. Jackson R, Brams MN, Citrome L, et al. Assessment of the impact of tardive dyskinesia in clinical practice: consensus panel recommendations. Neuropsychiatr Dis Treat. 2021;17:1589-1597.