Tardive dyskinesia

[lockian]

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Is anyone else freaked out by the idea of tardive dyskinesia? This may come from a place of not treating many patients with psychotic disorders, but when I see evidence of TD I always feel compelled to take the patient off the med immediately. Which is probably reasonable, unless they arrive to me on an LAI and they literally can't be taken off it quickly, or have severe/brittle SMI and there aren't many options. Still, I keep worrying that they will sue me for not taking them off a med fast enough that can cause TD's.

 

[deleted1100659]

Chances are though if you see TD, it has probably been there for a while, I would guess it didnt just start at that point in time. If its been going on for a while, patient usually has some awareness or the caregiver, unless its very very mild. I really dont see TD too often with SGAs, pretty rarely, but I do see it commonly with high potency FGAs or people on polypharmacy.

TD depending on the severity can improve or remit

1. Assess the dose they're on and use clinical intuition to see if the dose is way too high or if they're on unnecessary medications. Good collateral and patient giving a good history can help with that. If I start to see evidence of TD then generally I see if the patient can tolerate dose reductions

2. If they absolutely need to stay on the medication to remain stable for some reason and at that dose, then definitely familiarize yourself with ingrezza and austedo. I use ingrezza more, just because its easier for the patients to remember (qd vs BID dosing). And very easy to dose/titrate. See what the coverage is for your area and utilize patient support programs.

3. Switching to something like seroquel can improve TD sx as well but again this all depends on patients history

I see it so frequently that it does not really bother me and overall I tend to expect it. I use ingrezza a good bit, and have a ton of people on it. I have some on austedo but the dosing is more variable. The advantages of austedo though over ingrezza is austedo has less somnolence, and ingrezza requires dose reduction/holding at 40mg if someone on a 3a4 and I believe 2D6 inhibitor as well

If you complete AIMs each visit (I do it everytime generally, good to have that information on hand.

It would be very hard for them to sue you for TD if you were monitoring AIMs and keeping the patient informed and providing options/facts; its very easy to argue risk vs benefit here. Risk of stopping the medication vs continuing it and having TD.

But ingrezza can work very well for some people. Austedo too. Definitely gain experience with them,

 

[deleted1100659]

Also, just to add, many patients with TD dont want to stop their antipsychotic anyways because these tend to be the sicker patients and it has kept them somewhat stable, so they have a fear of decompensating.

 

[Candidate2017]

Is anyone else freaked out by the idea of tardive dyskinesia?

No.

Still, I keep worrying that they will sue me for not taking them off a med fast enough that can cause TD's.

Why would any psychiatrist freak out about common side effects? Especially if we follow the standard of care. All our meds have side effects. The more severe the disease, the more powerful meds are needed. And powerful meds come with severe, sometimes permanent side effects. Of which we discuss with patients and balance against benefits.

Assuming the patient has a psychotic disorder, was placed on an antipsychotic by their prior psychiatrist (not NP) and stabilized, why would you automatically rush to take them off their med? Especially when decompensation, hospitalization, and harm to their job, relationships, self, and others is a very real possibility.

 

[calvnandhobbs68]

Yeah I had attendings who made a decent argument actually that TD is a much less disabling side effect (at least to many patients) than gaining 50lbs because you're on zyprexa or seroquel or crazy hyperprolactinemia from risperdal. 2nd gen antipsychotic side effects also actually directly contribute to long term mortality (hyperlipidemia, hyperglycemia, weight gain) in a way that TD doesn't.

 

[deleted1100659]

Also consider this, if someone really gave you guff about it such as a caregiver then I would easily argue that that qualify of life impact from TD is meaningful and can be challenging to deal with, but pales in comparison from the quality of life impact from undertreated psychosis.

Schizophrenia is a spectrum, in terms of how I see it. There are the younger, more functional patients, the middle ground patients, and older/middle age more higher acuity patients. For the last subgroup, sometimes its just unrealistic to both adequately treat psychosis while having minimal SE. With caregivers and patients its always useful to be blunt/honest. Some people don't have full remission from symptoms and experience some AH at baseline, delusions, or paranoia, especially in those higher acuity people.

When you see TD, you address it however you can. Sometimes you just cant address, sometimes you can. It is an inevitable part of psychiatry really. I partly blame poor prescribing habits from inexperienced providers trying to take on the role of psychiatrists despite no real formal training in this. I think that has a decent amount to do with it.

I dunno, pick your poison i suppose. Psychosis, TD, metabolic issues. You dont have to be forced to have three but you're going to leave with at least one sometimes.

 

[Merovinge]

I would only be freaked out by TD if I was treating a non-chronic psychotic disorder or bipolar d/o. If the antipsychotic is treating BPD, amorphous problem disorder, long-term MDD (w/o psychotic features/ect/ketamine/tms need), and/or the patient is high functioning at baseline pre-treatment, then I would have significant concerns about TD. With SMI and good response, very hard to argue risks outweigh benefits.

 

[liquidshadow22]

What issues do people see with treating with ingrezza? I only used it one time and then referred to a movement specialist. HTN is the main issue usually correct, the rest of AE's are related to tolerance (sedation, dry mouth, headache, dizziness etc)?

 

[Stagg737]

What issues do people see with treating with ingrezza? I only used it one time and then referred to a movement specialist. HTN is the main issue usually correct, the rest of AE's are related to tolerance (sedation, dry mouth, headache, dizziness etc)?

$$$$$

 

[deleted1100659]

What issues do people see with treating with ingrezza? I only used it one time and then referred to a movement specialist. HTN is the main issue usually correct, the rest of AE's are related to tolerance (sedation, dry mouth, headache, dizziness etc)?

Generally well tolerated without any AE, never had someone get htn due to it. Most common reason people stop it is they feel sedated on it and dont like how it makes them feel.

If the patient has no insurance and minimal income, they will deliver it to the patients house for free. Which is quite a few schizophrenic patients. If they have commercial insurance then it can be harder. Medicaid coverage is generally crap in general. Medicare can cover it, i think its 50/50.

But again, low income and no insurance they can get it for free monthly.

I guess how i view is it simple. If they have TD why not at least try to prescribe it?? The worse that happens is it gets denied. But overall it doesnt change your treatment with the patient significantly. You either get it covered or dont get it covered. TD is a big deal for a lot of people, its worth at least trying to treat. And ingrezza is not complicated at all to prescribe as far as dosing/interactions