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Tardive Dyskinesia TARDIVE SYNDROMES PHENOMENOLOGY, PATHOPHYSIOLOGY, AND MANAGEMENT Cynthia Comella, MD, FAAN, FANA Professor of Neurological Sciences Rush University Medical Center Chicago, IL, USA Science never solves a problem without creating ten more George Bernard Shaw Objectives To describe the history of Tardive Dyskinesia To discuss epidemiology, risk factors and possible pathophysiologic mechanisms of tardive syndromes To demonstrate the varied phenomenology of TD To discuss treatment options for TD DOPAMINE RECEPTOR BLOCKING AGENTS (DRBA) AND TARDIVE DYSKINESIA Described in 1950’s within 5 yrs of development of chlorpromazine for psychosis Initial descriptions were drug induced parkinsonism Subsequently orobuccal-lingual movements persisting beyond medication discontinuation Continuous persistent movements in other regions subsequently described (limbs, face Term “tardive dyskinesia” in 1964 Frei K, Truong D, Fahn S, Jankovic J, Hauser R. J Neurol Sci 2018 Factor et al. Lancet Neurology 2019 DOPAMINE RECEPTOR BLOCKING AGENTS: ASSOCIATED MOVEMENT DISORDERS Acute disorders Acute dystonia Oculogyric crisis Sub-acute disorders Neuroleptic malignant syndrome Akathisia Parkinsonism Tardive disorders Stereotypy Chorea/athetosis Dystonia Akathisia (Tics, myoclonus, tremor) Dystonia Akathisia Neuroleptic Malignant Characteristic Tardive Dyskinesia Acute Tardive Acute Tardive Parkinsonism Syndrome Hours to Weeks to Days to Weeks to Days or weeks to Typical time to onseta Weeks to yearsb Hours to weeks days years months years years Choreoathetotic (irregular, dancelike), athetotic (slow, writhing), Tremor and/or and/or stereotypic bradykinesia; also, (repetitive, purposeless) rigidity of neck, Pulling, twisting, sustained, movements of the mouth, trunk, and and repetitive movements or jaw, tongue, and face Inner feeling of restlessness extremities, Generalized “lead- postures that are usually (mouth/jaw chewing, with urge to move and hypomimia, reduced pipe” rigidity with focal, involving the head, tongue protrusion, inability to maintain seated; blink rate, reduced tremor (less Movement neck, eyes, mouth, jaw, grimacing, lip smacking or may be associated with arm swing, flexed frequently: various phenomenology tongue, and face (torticollis, pursing, blepharospasm); stereotypies such as foot posture, and dyskinesias, trismus, jaw opening, also, and choreoathetotic tapping, shuffling, shifting shuffling or freezing dystonia, or grimacing, blepharospasm or and/or stereotypic weight, or rocking gait; also, rabbit myoclonus) oculogyric crisis, tongue movements of neck, trunk, syndrome (a protrusion, biting, or twisting) and extremities (piano- parkinsonian variant playing finger/hand that includes jaw movements, foot tapping, tremor) truncal rocking or thrusting) Jankovic et al, CNS Spectrums 2020 submitted Tardive Dyskinesia: DSM-5 Tardive Dyskinesia: 333.85 (G24.01) Involuntary movements (lasting at least a few weeks) generally of the tongue, lower face and jaw, and extremities developing in association with the use of a neuroleptic medication for at least a few months. Shorter exposure particularly in older individuals Persistent movements after this time point consistent with Tardive dyskinesia Withdrawal emergent dyskinesia can occur with dose reduction or discontinuation but resolve in 4-8 weeks Tardive Dystonia 333.72 (G24.09) Tardive Akathisia (G25.71) Tardive syndrome involving other types of movement problems American Psychiatric Association, 2013 Epidemiology Percent by phenomenology Tardive dyskinesia: 30% of pts on antipsychotics (20- 50%) Tardive akathisia: 20% Tardive dystonia: 5-15% Others are rare Long term risk 25% in 5 years 49% in 10 years 68% in 25 years Acquino and Lang. Parkinsonism Rel Disord 2014 Lerner et al. Psychiatr Clin Neurosci 2015 Type of antipsychotic agent 3 year incidence of Tardive dyskinesia Risk of TD Drug type Incidence of TD in 3 years HIGH Traditional antipsychotics 9% MEDIUM Risperidone 6% LOW Amisulpride, clozapine, 3% olanzapine, quetiapine (Novick et al, 2010, Baldessarin and Gardner, 2011) Prevalance in US 2011-2015 Loughlin et al. PLOS ONE 2019 TD in the United States (2011-2015) Retrospective observational study Optum EHR Database Review of 164,417 with new or repeat antipsychotic medication prescriptions Documentation of TD if present 1314 identified through diagnosis in clinical notes Annual prevalence TD in patients on DRBA 18-20 patients per 1000 79.8% received atypical antipsychotics Quetiapine, risperidone, aripiprazole, olanzapine Loughlin et al. PLOS ONE 2019 Prospective study comparing Olanzapine to conventional antipsychotics 231 patients with dementia and psychosis without TD (mean age 78 years, 53 % women) Open label Randomized to olanzapine (2.5-20, 118 mg/day CPZ) or conventional antipsychotic (118 mg/day CPZ equivalents) Treatment for up to 1 year Primary outcome: persistent TD ( > 1 month) Bruce J. Kinon et al. J Geriatr Psychiatry Neurol 2014;28:67-79 The Kaplan-Meier curves of time to tardive dyskinesia (TD) by varying degrees of dyskinesia severity and duration (P values are from log-rank exact test). Incidence of persistent TD of 2.5%. No difference OLZ vs CNV Bruce J. Kinon et al. J Geriatr Psychiatry Neurol 2014;28:67-79 DRBA’s associated with TD Typical and some “atypical” antipsychotics Phenothiazines (chlorpromazine, thioridazine, perphenazine, fluphenazine) Thioxanthenes (thiothixene (Navane®)) Butyrophenones (Haloperidol, (Haldol®)) Diphenyl butylpiperidine (pimozide (Orap®)) Thiennobenzodiazepine: (olanzapine (Zyprexa®)) Pyrimidinones ( risperdone (Risperdal®), iloperidone (Fanapt®), ziprasidone (Geodone®) Quinolinone (aripiprazole (Abilify®)) Martino et al. Can J Psych 2018 DRBA’s associated with TD DRBAs that are not considered antipsychotics but can cause TD Substituted benzamides (metoclopramide (Reglan)) Tricyclic antidepressant (amoxapine metabolites) Calcium channel blockers (flunarizine, cinnarizine) General rule: Drugs that can induce parkinsonism, can cause tardive dyskinesia with the exception of DA depletors. TD: risk factors Risk factors Increasing age (except for tardive dystonia) Increased incidence, prevalence Worse severity Less likely to resolve Female gender especially for oral-lingual buccal movements Longer duration of exposure More potent DRBAs: High affinity for D2 receptors Dose (chlorpromazine equivalents) TD: Clinical Characteristics Dyskinetic Movements: Stereotypies Chorea Dystonia: usually focal or segmental Retrocollis, opisthotnic posturing, truncal involvement Oromandibular and lingual Akathisia Often combinations of movement (complex) Tardive Dyskinesia: Chorea/stereotypy Distribution Oral-lingual buccal movements Distal limbs Trunk Respiratory Pattern Complex chewing movements, tong popping, piano-playng fingers and toes, truncal rocking, marching in place, respiratory dyskinesia Usually repetitive (stereotypy > chorea) Movements often suppressed by voluntary tasks Increased with stress Variably distractible Disability Significant disability, both functional and social with more severe symptoms Dentition Tardive dystonia Distribution Sustained muscle contractions, frequently with twisting component Abnormal postures, especially back arching and retrocollis Often seen in association with classical lingual-facial-buchal movements Extremities can be involved Painful in many instances Pattern Slow and sustained Geste antagoniste can be present In contrast to classical Tardive Dyskinesia, younger males are highest risk group Action exacerbated. Disability Can be painful and highly limiting in terms of sitting and walking Much more concerning to patients than classical tardive dyskinesia movements Tardive akathisia Distribution Leg and body restlessness: patient volitionally moves to relieve symptoms Often with classical lingual-facial buccal movements Pattern Leg kicking, truncal rocking Walking about and pacing relieves discomfort. Disability Distressful and very uncomfortable for patients Particular trouble sitting in a chair or standing in lines Early reports linked tardive akathisia to suicide risk Newer reports do not support links to suicide Tardive akathisia Tardive syndrome overlaps Combinations of dyskinesia/stereotypy, dystonia and akathisia frequent in tardive syndromes These combinations are of great diagnostic importance and highly suggestive of tardive syndromes. Diagnosis History of exposure DRBA for a few months Chorea, stereotypy, dystonia, akathisia usually in combinations temporally associated with DRBA Often worsens with reduction in DA blocker, improves with increased dose DA blocker Absence of other diagnoses Differential diagnosis Chorea/stereotypy type tardive dyskinesia Huntington’s disease and other neurodegenerative conditions Hepatolenticular degeneration Stereotypies of psychosis Edentulous dyskinesia Paraneoplastic dyskinesias Immune or metabolic dyskinesia SLE, thyroid, pregnancy, Sydneham’s chorea Infectious HIV Drugs causing dyskinesia (not tardive): Levodopa, tricyclics and other antidepressants, lithium, phenytoin Differential diagnosis Tardive dystonia Primary dystonias Wilson’s disease Secondary dystonias related to neurodegeneration Drug induced Tardive akathisia Primary akathisia Restlessness related to psychosis Restless leg syndrome Management: Prevention Very judicious use of DRBAs, including the not so atypical atypicals and metoclopramide Use of
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