Using VMAT2 Inhibitors Instead of Anticholinergics for Tardive Dyskinesia

Dr. Eiry Roberts discusses why clinicians should avoid anticholinergics in patients with tardive dyskinesia and opt for VMAT2 inhibitors instead.

A manuscript recently published in CNS Drugs explored the use of anticholinergics for patients with drug-induced movement disorders (DIMDs). According to the article, anticholinergics may be misused and overprescribed due to the misconception that all DIMDs can be treated the same way.

However, anticholinergics are not recommended for patients with tardive dyskinesia (TD). Eiry W. Roberts, MD, chief medical officer at Neurocrine Biosciences, emphasized that the use of anticholinergics for patients with TD can make symptoms worse.

Physician’s Weekly (PW) spoke with Dr. Roberts about how providers can support patients who develop TD with regular screening, early diagnosis, and appropriate prescribing.

PW: Can you discuss how TD impacts patients’ functioning?

Dr. Roberts: The uncontrollable movements of TD can negatively impact physical and psychosocial functioning and affect one’s ability to complete daily tasks, such as working, driving, or eating and drinking. People living with TD also may feel judged and ashamed, even from mild, uncontrollable movements, which adds to a sense of worry, isolation, and stigma in their daily lives.

What challenges do physicians commonly face when managing DIMDs?

Healthcare providers must understand the characteristic movements of different DIMDs, including TD, because recommended treatment strategies differ. Vesicular monoamine transporter type 2 (VMAT2) inhibitors are the preferred first-line treatment for TD. While anticholinergics may be used for some DIMDs, they are not recommended for TD. Routine screenings for abnormal movements in people taking antipsychotic medication are essential for detection, proper diagnosis, and appropriate management to help improve therapeutic outcomes. Appropriate screening can identify the potential presence and burden of TD.

Healthcare providers can visit MIND-TD.com for helpful information on identifying TD and differentiating it from other movement disorders. We also introduced DISCOVER TD™, an interactive digital tool to help them learn about and identify TD.

How can physicians improve early recognition and diagnosis of TD in clinical practice?

Proactive recognition, diagnosis, and treatment of TD can make a positive impact on the lives of many patients with psychotic and mood disorders. The American Psychiatric Association (APA) 2020 Clinical Guideline for the Treatment of Schizophrenia recommends screening for TD at least every six months in high-risk patients and at least every 12 months for others at risk of developing TD. It’s important to assess not only the possible presence and severity of TD but also the patient’s awareness of their abnormal movements and the impact of these symptoms on their overall wellness and daily functioning.

What are the potential risks associated with the misuse of anticholinergics for patients with TD?

Anticholinergics are not FDA-approved or recommended for the treatment of TD. Appropriate use of anticholinergics requires careful consideration of what the patient’s underlying disorder is and whether treatment will be safe and effective, especially in older adults and other vulnerable populations. Anticholinergics can worsen the symptoms of TD. Other adverse effects can include dry mouth, constipation, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased heart rate, and impaired cognition and memory loss, among others. The withdrawal of anticholinergics in patients with TD should be done with cautious tapering after considering the impact on concurrent conditions that may worsen upon anticholinergic withdrawal (such as drug-induced parkinsonism and tardive dystonia).

What role do VMAT2 inhibitors play in the treatment of TD?

VMAT2 inhibitors reduce the amount of dopamine released in a region of the brain that controls motor function. FDA-approved VMAT2 inhibitors are recommended as the first-line treatment for patients with moderate-to-severe TD by the APA 2020 Clinical Guideline and may be considered for patients with mild TD based on associated impairment, effect on psychosocial functioning, or patient preference. The roundtable findings discussed in the CNS Drugs manuscript, which reviewed existing literature, also recommend the use of VMAT2 inhibitors for the treatment of TD.

How can the findings of this study be incorporated into clinical practice?

While DIMDs share a common cause, many biological and clinical differences require accurate diagnosis and appropriate treatment choices. As the misuse and overprescribing of anticholinergics can worsen TD, it’s crucial that healthcare providers screen for the condition as part of their clinical routine for all patients on dopamine receptor blocking agents, such as antipsychotics, and consider VMAT2 inhibitors as first-line treatment.

Is there anything else you would like to add?

These data reinforce the importance of routine screenings for DIMDs, including TD, for patients taking antipsychotic medication, as proper screening is essential for early recognition and diagnosis. TD management requires an appropriate treatment strategy to achieve optimal clinical outcomes, and current evidence continues to support the use of FDA-approved VMAT2 inhibitors as the recommended treatment option. Neurocrine Biosciences is committed to partnering with stakeholders to continue advancing care and to advocate for routine screenings for those living with TD.