Tardive Dyskinesia: Comparing Medications

Tardive Dyskinesia: Comparing Medications

Tardive dyskinesia (TD) is a movement disorder induced by long term use of dopamine blocking medications. We don’t have many available treatment options for tardive dyskinesias. Physicians are using Tetrabenzaine as off label treatment and recently Valbenazine got FDA approval for TD treatment. Also a new medication, deutetrabenazine, is currently under FDA review as potential treatment for TD. 

This post will compare Tetrabenazine, Valbenazine and Deutetrabenazine.

 

  Tetrabenazine Valbenazine Deutetrabenazine
Mechanism of Action
  • VMAT2 inhibitor (non selective)
  • VMAT2 inhibitor (highly selective)
    • VMAT2 inhibitor

 

  • Derivative of tetrabenazine in which two trideuteromethoxy groups substitute two methoxy groups- this results in slow breakdown of metabolite. 
FDA Approved Indications
    • chorea associated with Huntington’s disease

 

  • Off label for TD treatment.
  • Adults with tardive dyskinesia
    • Chorea associated with Huntington’s disease

 

  • Off label for TD treatment: currently under FDA review.
Dose and Frequency
    • Starting dose is 12.5 mg daily; 2nd week, 25 mg (12.5 mg twice daily); may need three time dosing

 

  • Reason: Short half life.
  • Initial dose is 40 mg once daily. After one week, increase to recommended dose of 80 mg once daily
  • Half life of metabolite ~20 hr: so once daily dosing is preferred.
  • Dose from 24-36 mg/daily is shown to improve TD symptoms in randomized fixed dose trials. 
  • Dosing recommendations for Huntington’s chorea:  starting dose is 6 mg once daily. Titrate up at weekly intervals by 6 mg per day to a tolerated dose that reduces chorea, up to a maximum recommended daily dosage of 48 mg (24 mg twice daily).
Side Effects
    • Mood: Depression, suicidal ideations

 

    • Motor: Parkinsonism, akathisia

 

    • Sedation/ Somnolence

 

  • QTc prolongation
    • Sedation/ Somnolence

 

  • QTc prolongation
  • somnolence
  • diarrhea
  • dry mouth
  • fatigue
CYP2D6 Monitoring
  • Patients requiring doses above 50 mg per day should be genotyped for CYP2D6 to determine if patient is a poor metabolizer or extensive metabolizer
  • Not indicated
  • Not indicated
Cost 
  • 25 mg tabs # 30 tabs: price range from ~1,500- $3,500 (out of pocket). Price may vary if approved by insurance.
  • 40 mg caps # 30 caps: price range from ~$5,400- $5,800 (out of pocket). Price may vary if approved by insurance.
  • 12 mg tabs # 60 tabs: price range from ~$5000- $$5270 (out of pocket). Price may vary if approved by insurance. 

 

VMAT2 inhibitor: vesicular monoamine transporter 2 inhibitor.

Source: 

  1. CNS Spectr. 2016 Dec;21(S1):13-24.
  2. Package insert for individual medications above.
  3. Source for cost: GoodRx with Location: Philadelphia PA
 

Please do post your questions or comments below. 


Dr. Harvinder Singh, M.D. (Admin)


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