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How to Treat Tardive Syndromes in Your Practice

Guideline Watch |
September 3, 2013

How to Treat Tardive Syndromes in Your Practice

  1. Michael S. Okun, MD

New guidelines from the American Academy of Neurology are based on limited evidence.

  1. Michael S. Okun, MD

The American Academy of Neurology (AAN) has published a new guideline offering several evidence-based recommendations for addressing tardive syndromes that result from use of a dopamine receptor blocker. Using standard AAN guideline methodology, the authors made the following recommendations:

  • Evidence is insufficient to support withdrawal of dopamine receptor blocking agents as an effective treatment for tardive syndromes or to support switching from typical to atypical dopamine receptor blockers to improve symptoms.

  • The highest level of existing evidence favored clonazepam and ginkgo biloba (Level B).

  • Although some studies cite risperidone as a treatment, others identify it as a cause.

  • Amantadine and tetrabenazine reached a Level C recommendation for treatment.

  • Diltiazem was not an adequate treatment (Level B), nor was galantamine or eicosapentaenoic acid (Level C).

  • All other therapies failed to reach an evidence-based recommendation. Information was insufficient for a recommendation about botulinum toxin or surgical therapies (e.g., deep brain stimulation or pallidotomy).

Comment

Tardive syndromes occur in about one third of patients with schizophrenia treated with dopamine blocking agents and can also occur in other disorders. The syndrome also can result from treatment of a common headache disorder (e.g., with compazine or phenergan), or gastrointestinal malady (with metoclopramide). A diagnosis of a tardive syndrome requires that other disorders be excluded, and the patient must be exposed to a dopamine receptor blocker for at least 3 months and have moderate hyperkinetic movements, or mild hyperkinetic movements in two or more body regions. Although this guideline provides some information for practicing clinicians, most of the studies have been small and poorly designed. Movement-disorder experts usually address tardive syndromes by switching to dopamine-depleting strategies (e.g., tetrabenazine) while monitoring for drug-induced parkinsonism and other adverse effects of these drugs. Most agree that atypical dopamine blocking agents are safer than typical dopamine blockers (e.g., haloperidol). Additionally, mounting evidence supports pallidal deep brain stimulation as effective in suppressing many of the hyperkinesias in tardive dystonia and tardive dyskinesia (Parkinsonism Relat Disord 2013; 19:141).

  • Disclosures for Michael S. Okun, MD at time of publication Grant / research support NIH; National Parkinson Foundation; Michael J. Fox Foundation Editorial boards Parkinsonism and Related Disorders; Tremor and Hyperkinetic Disorders Leadership positions in professional societies National Parkinson Foundation (Medical Director and Ask the Doctor Director); Tourette Syndrome Association (Medical Advisory Board)

Citation(s):

Reader Comments (5)

RENAN MACIAS Physician, Neurology, Office

Excellent piece of information to every physician.

RICHARD STORCH Physician, Psychiatry, hospital

What abour clozapine???

Lisa McMurray Physician, Psychiatry, Royal Ottawa Mental Health Centre

I am surprised that there is no specific mention of Clozapine.

Lex Denysenko Physician, Psychiatry, Psychosomatic medicine

I've had success with vitamin B6 at 500mg BID.

Terri Squires, LPC, FNP-C, PMHNP-C Other Healthcare Professional, Psychiatry, own company

I researched years ago various tx for TD and although one study only suggested zyprexa to be effective for TD. I used Zyprexa for a diaphragmatic TD patient previously on Risperdal for years. Guess what--TD remitted successfully with Zyprexa and withdrawing Risperdal--I have also tried amantadine with no results although one study suggested it was effective. Interesting you didn't mention Zyprexa--please note me if you use it

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