Published: March 2013

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Adverse Reaction Reminder: Tardive Dyskinesia

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Prescriber Update 34(1):4-5
March 2013

Tardive dyskinesia is a serious adverse effect, characterised by repetitive, involuntary, painless movements. Features of tardive dyskinesia typically appear after months or years of antipsychotic use. Importantly, this condition is often non-reversible and difficult to treat.

The lower face is primarily affected, with symptoms such as facial grimacing, repetitive chewing, tongue protrusion, and lip smacking¹. Less commonly, muscles of the eyelids, neck, torso and extremities are affected.

Tardive dyskinesia has mainly been associated with antipsychotics. Other medicines also associated with tardive dyskinesia include antiemetics (eg, metoclopramide), antihistamines (eg, promethazine), and antidepressants (eg, selective serotonin reuptake inhibitors and tricyclic antidepressants).

The exact mechanism is not fully understood. However, tardive dyskinesia is generally believed to be a result of long-term blockade of dopamine D2 receptors in the nigrostriatal pathway. This blockade results in increased sensitivity and an abundance of dopamine receptors, producing altered movements.

It has been estimated that 15-30% of people on long-term antipsychotics may be affected by tardive dyskinesia¹. The incidence is much higher with the use of first generation ('typical') antipsychotics, than second generation ('atypical') antipsychotics. However, the use of atypical antipsychotics does not exclude the possibility of developing tardive dyskinesia.

Severity of tardive dyskinesia ranges from isolated dyskinesias that are not noticed by the patient, through to disabling effects which interfere with day-to-day activities such as walking and talking.

Diagnosis follows physical and neuropsychiatric evaluation, while other movement disorders must be excluded. Reducing the dose or withdrawing the causative agent where possible may be beneficial. Alternatively, switching to another medicine with a lower risk of tardive dyskinesia could be considered.

Other risk factors for the development of tardive dyskinesia include increasing age, a history of alcohol or substance abuse, developmental disabilities, and extra-pyramidal symptoms at initiation of therapy. The risk is also higher in post-menopausal women.

In New Zealand, 17 cases of tardive dyskinesia were reported to the Centre for Adverse Reactions Monitoring (CARM) between January 2000 and December 2012. The majority of cases were associated with risperidone (8 reports). A total of 13 cases were associated with the use of an atypical antipsychotic, either alone or in combination with another medicine known to be associated with the development of tardive dyskinesia.

The increased reporting of tardive dyskinesia with atypical antipsychotics over typical antipsychotics is likely due to the increased use of atypical antipsychotics and the increased awareness of this possible adverse effect.

Healthcare professionals are encouraged to report these reactions to CARM and to include as much information as possible to help identify other medications or risk factors that may be associated with this serious adverse effect.

References

1. Brasic JR. 2012. Tardive Dyskinesia. Medscape. URL: http://emedicine.medscape.com/article/1151826-overview#showall (accessed 5 February 2013).