Karen Elta Anderson, MD, prepared useful practice aids pertaining to tardive dyskinesia for this CME activity titled "Finding the Path to Improved Recognition and Management of Tardive Dyskinesia." For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/37MqcXB. CME credit will be available until September 27, 2021.

1. Tardive Dyskinesia Screening and Assessment1-6
Full abbreviations, accreditation, and disclosure information available at PeerView.com/EMM40
Any patient taking any agent
with DRB properties
• Ask about TD symptoms at every clinical encounter
• Anticipated review of abnormal movements
• Visual observation
• Caregiver report
• Patient report: movements and effects on function/QoL
• Abnormal Involuntary Movement
Scale (AIMS; eg, every 3 to 12 months,
depending on risk factors)
Routine semistructured
assessment
Less frequent
structured assessment
Total score (categories I, II, III) is calculated
to represent observed movements
Items
1-7
Used as an overall severity indexItem
8
Provide additional information that may be
useful in clinical decision-making
Items
9-10
Yes/no questions concerning teeth,
dentures, edentia, and sleep
Items
11-14
AIMS Overview
Screening for TD

2. Tardive Dyskinesia Screening and Assessment1-6
Full abbreviations, accreditation, and disclosure information available at PeerView.com/EMM40
1. Johnson BG. Nursing. 2017;47:56-60. 2. Caroff SN et al. J Clin Psychiatry. 2020;81:19cs12983. 3. Caroff SN et al. Psychiatr Clin North Am. 2016;39:391-411. 4. Correll CU et al. J Clin Psychiatry. 2017:78:1136-1147. 5. Citrome L at al. Am J Manage Care. 2007;13(Suppl):1-12. 6. Kane JM et al.
J Clin Psychiatry. 2018;79:17cs11959.
Criteria
• Involuntary movements during exposure to or
after withdrawal from antipsychotic or other
dopamine-blocking agent
• Differential diagnosis
• Patient history
• Cumulative exposure to antipsychotic medication
• Current medication
• Duration and severity of involuntary movements
Consider neurologic consultation in these cases
• Atypical presentation or course
• Family history of movement or
neurodegenerative disorders
• Presence of other signs/symptoms
• Uncertainty in tardive dyskinesia diagnosis
• Unexpected treatment response
More Common
• Akathisia
• Drug-induced parkinsonism or tremor
• Edentulous dyskinesia
• Spontaneous dyskinesia
• Drug-induced dyskinesia caused
by other agents
• Chronic motor tics
• Autism
• Blepharospasm
• Huntington’s disease
• Meige syndrome
• Psychotic stereotypies
• Restless leg syndrome
• Senile chorea
• Sydenham chorea
• Tourette syndrome
• Wilson disease
• Rett syndrome
Less Common
Diagnosis of Tardive Dyskinesia
Tardive Dyskinesia: Differential Diagnosis

3. Recommendations:
Use of Adjunctive Therapies for TD1
Full abbreviations, accreditation, and disclosure information available at
PeerView.com/EMM40
1. Bhidayasiri R et al. J Neurol Sci. 2018;389:67-75.
Troublesome
symptoms
Nontroublesome
symptoms
Nonapproved
indications
Level A:
New VMAT2
inhibitors
(or tetrabenazine)
Level B:
Clonazepam or
Ginkgo biloba
Level C:
Amantadine
Level C:
GPi DBPS
Determining
lowest
effective dosage
Determining
lowest
effective dosage
Review by
specialist to identify
suitable alternative
Improved
Improved
Improved ImprovedImproved
Improved
Not improved and
still troublesome
Not improved and
still troublesome
Not improved and
still troublesome
Not improved
and still
troublesome
Context for
antipsychotic/
dopamine-blocking
agent use
TD assessment
Dosage evaluation
Consider
suppressive
agents
Monitoring and
follow-up
assessment
Close observation
and regular
follow-up
Close observation
and regular
follow-up
Approved
indications
Tardive dyskinesia

4. FDA-Approved VMAT2 Inhibitors for TD1-3
Full abbreviations, accreditation, and disclosure information available at PeerView.com/EMM40
a
Also consider hypersensitivity to compounds related to valbenazine (ie, tetrabenazine, deutetrabenazine).
Characteristics of VMAT2 Inhibitors
Characteristic Valbenazine Deutetrabenazine
Dosing frequency Once daily Twice daily
Initial dose 40 mg/d 12 mg/d (divided doses)
Recommended dose 80 mg/d 12-48 m/d (divided doses)
Administer with or without food With or without With
CYP interaction (substrate) CYP2D6, CYP3A4 CYP2D6
Contraindications
Monoamine oxidase inhibitor,
valbenazine hypersensitivitya
MAOIs, valbenazine, reserpine,
tetrabenazine, hepatic impairment
Warnings/precautions
Impaired driving/somnolence,
QT prolongation, parkinsonism
Impaired driving/somnolence, QT prolongation,
parkinsonism, neuroleptic malignant syndrome
Common adverse events Somnolence Nasopharyngitis, insomnia

5. FDA-Approved VMAT2 Inhibitors for TD1-3
Full abbreviations, accreditation, and disclosure information available at PeerView.com/EMM40
a
Cases deemed not related to valbenazine; one case possibly related to deutetrabenazine (long-term trial in Huntington disease found no relationship).
1. McEvoy JP, Kremens DE. J Clin Psychiatry. 2020:81:1:NU18041AHSC. 2. Factor SA et al. J Clin Psychiatry. 2017;78:1344-1350. 3. Fernandez HH et al. J Neurol Neurosurg Psychiatry. 2019;90:1317-1323.
Outcome Valbenazine (N = 189, 52 weeks) Deutetrabenazine (N = 343, 106 weeks)
Any AE, n (%) 137 (69.2) 233 (67.9)
Any AE leading to discontinuation, n (%) 31 (15.7) 26 (7.6)
Any serious AE, n (%) 29 (14.6) 45 (13.1)
Suicidal ideation, n (%) 10 (5.1)a
16/342 (5)a
AEs with incidence ≥5% Headache, UTI, diarrhea, dizziness
Headache, UTI, somnolence, depression,
anxiety, diarrhea, nasopharyngitis
Safety Outcomes in Long-Term Trials of Valbenazine and Deutetrabenazine
Long-Term Efficacy of Valbenazine and Deutetrabenazine
AIMS Mean Improvement With Deutetrabenazine
Time, week
MeanChangeFrom
BaselineinAIMSScore
-10
- 8
- 6
-4
-2
0
0 11040 50 60 70 80 90 100302010
AIMS Mean Improvement With Valbenazine
Time, week
-7
-6
-5
-4
-3
-1
-2
0
1
0 32 48 52166 8
AIMSScoreMeanChange
FromBaseline(±SEM)
End of
DBPC
End of
washout
End of
extension