TD Management

Recognition & Screening

Recognizing tardive dyskinesia (TD) symptoms in patients

An exam may benefit all patients at risk for TD, as even mild symptoms
can cause distress^1,2

Screening for abnormal movements can be accomplished by observation and activation.

Abnormal movements can be identified when the patient is walking to the consultation room and during conversations with the patient.²

Activation maneuvers can help unmask movements that occur under specific circumstances (for
example, during a daily activity outside of the examination setting).³

Use the TD Estimator Tool to see how many patients in your practice may have TD

Activation maneuver techniques^2,4

A man sitting on a chair with arms held out front of him.

Ask the patient to:

Extend arms in front of the body and count backwards from 100

Observe:

Hands and arms

Ask the patient to:

Hold mouth open and stick tongue out while tapping thumb to forefinger with both hands

Observe:

Tongue and face

Ask the patient to:

Walk in a straight line with usual gait and posture

Observe:

Hands, arms, tongue, and face

Clinical assessments should be performed at every visit for all patients taking antipsychotic drugs (APDs)⁵

For patients starting APDs, use AIMS to screen and establish a baseline regarding movements. The American Psychiatric Association recommends that a full AIMS assessment be performed at least every 6 months for patients at high risk. In between these formal evaluations, semistructured, AIMS-informed assessments should be performed at every visit.^5,6

Semistructured assessments may include^5,6:

Patient recognition of abnormal movements when reviewing APD side effects
Visual observations during examination
Patient or carepartner report of abnormal movements
Patient complaints of movements being distressful or interfering with daily life

If the semistructured assessment reveals abnormal movements, a full AIMS assessment should be performed.^5,6

LEARN MORE: IN-PERSON AND VIRTUAL
AIMS ASSESSMENT FIND INFORMATION ON DIFFERENTIAL DIAGNOSIS

AIMS, Abnormal Involuntary Movement Scale.

REFERENCES: 1. Yassa R. Functional impairment in tardive dyskinesia: medical and psychosocial dimensions. Acta Psychiatr Scand. 1989;80(1):64-67. 2. Munetz MR, Benjamin S. How to examine patients using the Abnormal Involuntary Movement Scale. Hosp Community Psychiatry. 1988;39(11):1172-1177. 3. Data on file. Parsippany, NJ: Teva Neuroscience, Inc. 4. Abdo WF, van de Warrenburg BPC, Burn DJ, Quinn NP, Bloem BR. The clinical approach to movement disorders. Nat Rev Neurol. 2010;6(1):29-37. 5. Caroff SN, Citrome L, Meyer J, et al. A modified Delphi consensus study of the screening, diagnosis, and treatment of tardive dyskinesia. J Clin Psychiatry. 2020;81(2):19cs12983. doi:10.4088/JCP.19cs12983 6. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Schizophrenia. 3rd ed. American Psychiatric Association; 2021.

Important safety information

Depression and Suicidality in Patients with Huntington’s Disease: 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 is contraindicated in patients who are suicidal, and in patients with untreated or inadequately treated depression.

Contraindications: AUSTEDO is contraindicated in patients with Huntington’s disease who are suicidal, or have untreated or inadequately treated depression. AUSTEDO is 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 (Xenazine^®) or valbenazine (Ingrezza^®).

Clinical Worsening and Adverse Events in Patients with Huntington’s Disease: AUSTEDO may cause a worsening in mood, cognition, rigidity, and functional capacity. Prescribers should periodically re-evaluate the need for AUSTEDO in their patients by assessing the effect on chorea and possible adverse effects.

QTc Prolongation: AUSTEDO may prolong the QT interval, but the degree of QT prolongation is not clinically significant when AUSTEDO is administered within the recommended dosage range. 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; intensive symptomatic treatment and medical monitoring; and treatment of any concomitant serious medical problems.

Akathisia, Agitation, and Restlessness: 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 dose should be reduced; some patients may require discontinuation of therapy.

Parkinsonism: 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 dose should be reduced; some patients may require discontinuation of therapy.

Sedation and Somnolence: Sedation is a common dose-limiting adverse reaction of 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 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.

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.

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Recognizing tardive dyskinesia (TD) symptoms in patients

An exam may benefit all patients at risk for TD, as even mild symptoms can cause distress1,2

Activation maneuver techniques2,4

Clinical assessments should be performed at every visit for all patients taking antipsychotic drugs (APDs)5

An exam may benefit all patients at risk for TD, as even mild symptoms
can cause distress^1,2

Activation maneuver techniques^2,4

Clinical assessments should be performed at every visit for all patients taking antipsychotic drugs (APDs)⁵