Anticholinergics Not Recommended for Treating Tardive Dyskinesia

An expert panel of psychiatry and neurology clinicians agree with current treatment guidelines that anticholinergics should not be used to treat tardive dyskinesia (TD). The study findings were presented at Psych Congress 2022, held September 17 to 20, 2022.

Tardive dyskinesia is a hyperkinetic movement disorder associated with dopamine receptor blocking agents. Prior to the approval of valbenazine and deutetrabenazine for the treatment of TD, off-label medications such as anticholinergics and tetrabenazine were used for managing TD, despite a lack of evidence supporting their efficacy. Even though there are now approved medications for TD, some patients continue to receive off-label medications.

To better understand the real-world treatment practices of TD, an expert panel comprising 4 psychiatrists, 1 geriatric psychiatrist, 1 psychiatric physician assistant, 1 psychiatric nurse practitioner, and 1 neurologist met in November 2020. A second panel of 5 psychiatrists, 1 geriatric psychiatrist, 1 psychiatric physician assistant, 1 psychiatric nurse practitioner, and 1 neurologist specializing in movement disorders met in June 2021. The panels formulated and discussed 13 potential consensus statements about use of anticholinergics in TD.

Panelists agreed with the guidelines from the American Psychiatric Association that all patients taking antipsychotic medications should be monitored for TD and all other drug-induced movement disorders.

First-line treatment for TD should be the United States (US) Food and Drug Administration (FDA)-approved vesicular monoamine transporter 2 (VMAT2) inhibitors valbenazine or deutetrabenazine, the panelists noted.

Clinicians added that anticholinergics do not improve and may worsen TD symptoms. Anticholinergics may, however, be considered for use among patients at high risk for acute dystonia, but prolonged use should be avoided, the panelists explained. Long-term exposure to anticholinergics may have potential cognitive and peripheral adverse effects. The risk for cognitive affects makes anticholinergics potentially harmful for vulnerable populations, such as older patients and those with cognitive disorders. When discontinuing, anticholinergics should be tapered slowly. Abrupt discontinuation may result in cholinergic rebound.

Panelists also explained that the misuse of the classification “extrapyramidal symptoms” contributes to patients continuing to receive incorrect therapies. “Extrapyramidal symptoms” is an all-encompassing term for acute and tardive neuroleptic-induced movement disorders, which does not differentiate by presentation, pathophysiology, or treatment. A gap in general knowledge on various drug-induced movement disorders is also a contributing factor, experts added.

Study authors concluded, “Anticholinergics are not recommended for the treatment of TD and may aggravate or unmask TD. The misunderstanding and misuse of the term ‘extrapyramidal symptoms’ for all drug-induced movement disorders and the continued educational need on TD differentiation contribute to a lack of knowledge, which can lead to inappropriate treatment.”

Disclosure: This research was supported by Neurocrine Biosciences, Inc. Please see the original reference for a full list of disclosures.

This article originally appeared on Psychiatry Advisor.