tardive dsykinesia

How I Treat Tardive Dyskinesia

Psych Management
Psych Team

Welcome, if you are new here, I usually ramble about things dealing with psych and it makes me excited. I think health providers NEED to hear something positive and love hearing about success stories. For example, let me tell you about how I’ve been dealing with tardive dyskinesia lately. Long story short, I don’t.

This isn’t clickbait but I wanted to focus on how important it is to treat abnormal movements. The moment a patient tells me that they’re having an increase of abnormal movement, I find the culprit and treat it till remission.

First, let’s discuss what extrapyramidal side effects (EPS) are real quick. It’s basically neuromuscular symptoms and a major side effect of antipsychotics. These symptoms include acute dystonia, pseudoparkinsonism (drug-induced Parkinsonism), akathisia (or how I like to remember it, Kathy is moving!), and tardive dyskinesia. TD can be irreversible, which is why it’s so serious and considered a complication of EPS.  EPS results from blocking dopamine, specifically d2 receptors that are commonly used to treat psych disorders and a decrease in dopamine is the etiology of Parkinson’s Disease. A Quick Review About Dopamine

EPS is an increase of ANY uncontrolled movement/activity due to antipsychotics

Whether the patient is psychotic or not, I prioritize EPS while treating the mental health conditions. I inherit a patient (let’s call her Kathy) who was on haloperidol 5mg TID and aripiprazole at 45mg QHS, she was also on quetiapine, an antidepressant, and a mood stabilizer. She continued to be paranoid and heard voices so I increased the haloperidol to QID. Voices left but on her next visit, her hands were mildly shaking. Added benztropine and shaking stopped but still restless with auditory hallucinations lingering. Next visit, decrease haloperidol to TID, voices were gone, and no abnormal movements.

Kathy was already on a high dose of the aripiprazole so I decided to wean that med to d/c it because it didn’t help. The voices stopped with the haloperidol but the aripiprazole could have induced the EPS or made it worse. With dopamine, it’s all about balance and when it’s off/decreased, it can throw everything off and physically manifest the symptoms.  A Quick Review About Acetylcholine

I’m Weaning My Life Away

I’ve posted some links below and the general consensus is to decrease the antipsychotic dose first. However, if the dose is too low, it’s ineffective and psych symptoms may get worse. Therefore, whatever isn’t working is getting wean till it’s d/c’d. Some literature assumes it’s mainly with FGA’s. However, I’m inheriting young and healthy patients with these abnormal movements on SGA’s, even at low doses so I am weaning. I wean until the movements stop or if psych symptoms have been resolved at least for a month, I wean to d/c.

This is honestly the part where benzos don’t deserve to put in a timeout corner because it’s better than having EPS and TD. If they have to stay at a certain antipsychotic dose, using benzos is an appropriate way to prevent these symptoms from getting worse. But we all know the problem with benzos and addictions! so with every f/u, I consider weaning, switching medications, and of course r/o drugs or other factors.

Kathy was previously on lorazepam .5 mg TID and she wanted it prescribed again. I didn’t restart it but focused on starting another med for her “anxiety”.  She didn’t have any obvious abnormal movements but looking in hindsight, it was like she was speaking in code that it was becoming an issue. Another patient said he had subtle movements in his chest. Again, not obvious but if there are no psych symptoms, I wean the antipsychotics and start/continue/increase benztropine.

Patients who have schizophrenia sometimes speak in coded ways. Kathy didn’t want to admit that this was a problem until her hands were shaking and the problem was finally showing itself. I was considering restarting the lorazepam because you can truly see the s/e’s affecting a person’s life but the key is reducing polypharmacy, not adding more meds. The previous prescriber had her on all these medications but she wasn’t getting better so it was time to get rid of what you can.

Think about it, clinical schizophrenia is like <2% of the US population (per NIH), therefore most of the time psych symptoms can be transient or short-term, it doesn’t have to be forever. TD should not be a problem especially if you treat the EPS. Lifelong or a permanent use of antipsychotics is then mainly for a small portion of the population like Kathy but if not, consider antidepressants, stimulants…almost anything else besides a medication that is worsening a person’s movement.

  • Risk of TD by Medication (from low to high): Quetiapine/Clozapine -> Aripiprazole/Asenapine/Iloperidone/Lurasidone/ Olanzapine/Ziprasidone -> Paliperidone/Risperidone -> Low-potency FGA i.e. chlorpromazine -> High-potency FGA i.e. haloperidol or fluphenazine
  • Strategies in the pharmacological treatment of TD include: tapering the offending drug, switching to a second-generation antipsychotic, or adding a drug to neutralize the side effects. Suggested drugs are: clozapine, vitamin E, buspirone, benzodiazepines, among others. The only drug that has shown substantial evidence of efficacy is clozapine.

–Read More About Complications of Treatment

How to Wean

I have weaned multiple people off their antipsychotics and if it’s a low dose, I just tell them to stop that day and replace it with a different medication if needed. However, with high doses or if the psych symptoms have subsided, I ween half the dose for one week, half that dose the next week, half it again, then d/c the dose if no mental issues have occurred.

If you are concerned about weaning or the psych symptoms returning, you can ask the client to call the office or do a quick wellness check. Plus working with the therapist and family to make sure everyone is on the same page and for backup support also helps. Then after weaning the antipsychotics, I’ll wean the benztropine until the movements are gone. If they have to be on antipsychotics (schizophrenics i.e.) then I’ll keep the benztropine.

Kathy was on 3 antipsychotics, I went up on the haloperidol mainly because the aripiprazole was maxed out (Abilify was at 45mg). But when her hands started to shake, I went down on haloperidol and halved/wean the dose of Abilify, and discontinued it. Side note: you have to wean high doses of Abilify but since she was on other antipsychotics the wean could be aggressive. The quetiapine was not an issue but overall try to keep/maintain a person on <2 antipsychotics if there are EPS concerns. I have adults and kids on 2 antipsychotics that are doing exceptionally well but no abnormal movements, because if so I’ll start my weaning or switching processes.

You can wean on the 1st appointment but sometimes I start on the f/u or let the patient know my plans and if they agree, we can start at that moment or in the near future. It’s truly based on the comfort level, the psych issues, and the severity of the EPS symptoms. Usually, once the patient gets what’s going on, they are not hesitant and actually happy about taking fewer medications and worrying less about s/e…treating eps

What’s The Point?

Every patient needs to know how serious these s/e can get. Even if they love the medication, NO one wants or loves abnormal stuff that’s unnecessary. EPS will cause a person to be more withdrawn, decrease the quality of life, and make anxiety/depression worsen due to the sheer embarrassment alone.

Therefore, I don’t wean for the EPS alone. If a person is in zombie mode, drooling, feeling, or getting better, or if I have to start using more medications to treat the side effects, I’m weaning to d/c or going into a different class of medications. If my pediatric patients are overweight, have metabolic issues/family hx, I’m using low-dose antipsychotics until stability, wean or consider going into a different class of medications but with kids, failed medications are usually related to poor behavior outcomes and not EPS.

EPS is different and I treat it like a complication. I can titrate antipsychotics up based on the behavior but with EPS I’m looking to d/c the dose or try to decrease the dose to resolve it. If I can’t lower the dose to fix it, I’ll switch the psych med and start at the lowest dose or consider a mood stabilizer if I’m targeting the behavior. If the person is good on a mood stabilizer, I’ll still try to decrease the antipsychotics. With all antipsychotics or especially with kids, start low and go/up slow. Not only is it safe practice but you can track almost any abnormal activity or a s/e very easily.

Sometimes you can try to cross-taper but it’s not that simple. Low potency drugs can still cause EPS and you want to take precautions starting a new medication at a high dose due to the risks of s/e. But if you’re in my boat or in the hell of community mental health and attracting all types of people on everything, try to decrease the dose or wean the psych medications and add/increase/continue benztropine till remission.

Another Wean

For kids, I’m concerned about weight and metabolic issues and for adults, I’m worried about falls/abnormal movements + metabolic s/s with antipsychotics. For EVERYONE I assess EPS at every follow-up especially with telehealth since you can’t visibly see the patient. I had to pull up previous records to see what had happened then the person finally admitted to the problem. I assume this other particular patient (we can call him Joe) was aware since he was on benztropine, but he had no idea and was on 5mg of Abilify/day.

Joe told me everything was good but another doctor was prescribing the benztropine and past records (that I didn’t have at the time) reported motor movements in his toes and was drooling. He stop drooling but had small movements even after switching to a smaller dose. He stop having bizarre behavior and agreed to d/c the antipsychotics. The abnormal movements eventually stopped and now he’s currently going around the family again and going out of the house more often. This was ALL telehealth but if hallucinations occurred again, I would go in the direction that would cause the least amount of EPS.

So now I ask if there are any weird or funny movements anywhere on the body with just about everyone who was ever on psych meds because EPS can last from months to years despite not being on the medication. It’s one of the main reasons people stop taking their medications in the first place.

People assume they need Xanax or anything because of this shaky restlessness when it’s actually EPS that needs to be addressed. It may be tedious to keep asking the same questions but it gets easier. What is difficult is waiting until the movements are so bad that you can’t r/o the culprit or know what medication will make it better or worse!?

TD can be permanent and medications i.e. valbenazine (Ingrezza) or newer agents may help but if you have Medicare/Medicaid patients, coverage or the co-pays can be difficult!! and meanwhile, the patient is usually getting mentally and physically worse. Use the antipsychotic and/or benzo to discover or find a medication that is working (not causing EPS) so you don’t end up on the slippery slope.

Getting Around The EPS

If you can find the culprit, you’ve already won half the battle. For example, with Kathy, it was increasing the haloperidol and not her aripiprazole that caused the problem so I decrease the haloperidol dose with plans to d/c the aripiprazole because that can trigger more movements and it was maxed out. She is my true schizophrenic so I have to continue something and since the audible hallucinations resolved, I was able to focus more on the medication to d/c, avoid, or decrease due to EPS risks and side effects.

For my other patient Joe, he had short-term hallucinations, poor sleep, and bizarre behavior so I inherit him on a small dose of aripiprazole pending IM injections. I wasn’t aware that he also had EPS symptoms and was being treated for it until he finally told me what was going on. Side note: some people being prescribed benztropine don’t know why or disclose it because it’s not a “psych” med. He didn’t want an IM shot so I switched him to a small dose of olanzapine and the EPS was still occurring but the psych symptoms subsided so I just d/c the medication since it was a small dose.

Joe is doing better with just an antidepressant and currently sleeping well but if I had to give him something to sleep it’ll be doxepin, trazodone, clonidine…etc. (anything but an antipsychotic). If he had bizarre behavior again then I’ll try low-dose olanzapine again (for sleep and psych symptoms) and if needed, restart the benztropine. So just because you don’t know which medication is causing the EPS, doesn’t mean you can’t start weaning. If you can d/c the dose (no psychotic symptoms), try to stop it, especially if side effects keep occurring.

EPS is mainly from psych medications, especially from aripiprazole but it can be others, such as prochlorperazine (Compazine). Joe had poor sleep so I trialed mirtazapine, but he was allergic to it, unbeknownst to him. Therefore, use a Gene Site to make sure there won’t be extra interactions or s/e. I usually can’t do this with my adults because it costs at times but I try to do it with all my kids or before they turn 18 since they don’t have to pay with government insurance…

Adults can be tricky (co-morbidities, substance abuse, adherence) so that’s why it’s important to start low and go slow, if there are any movement issues lower the dose, switch, or consider benztropine or a BZD (if severe) while assessing for improvement and trialing different medications with the least amount of s/e to deal with the mental conditions.

Final Note

Why do I sometimes wean the benztropine? Because I don’t want the body to build up a tolerance to like the only medication that actually works. And it’s usually COVERED. It restores the balance between dopamine and acetylcholine to reduce the motor s/e and it shouldn’t be an issue to d/c it once the EPS/antipsychotic is gone and there are no other conditions like Parkinson’s.

However, I usually keep my classic schizophrenia patients on it or tell them to use it as a PRN. My patient Kathy was doing that anyway and said it helped make the extra movements go away (before d/cing the aripiprazole). Benadryl and other medications may work but I want to have the safest and best backup available as often as possible. Plus, don’t forget about avoiding polypharmacy or extra s/e.

You can do benztropine 4mg BID, add Metformin, hydroxyzine TID PRN…etc but more medications equal a greater risk for more problems. Don’t use more medications to treat worsening side effects especially if the patient isn’t getting better. Definitely read the writing on the wall and if something is getting worse, you have to do something about the causing agent. Wean and d/c it! You have all these great options to AVOID EPS/TD. The body acts strange, especially in psych…I’m done rambling :))

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