Anticipating Medication Interactions in Tardive Dyskinesia

When certain medications may contribute to or exacerbate the development of a disorder, like in tardive dyskinesia (TD), it is especially important for clinicians to consider potential medication interactions before initiating treatment. 

Filmed at the 2024 Psych Congress NP Institute, Desiree Matthews, PMHNP-BC, Steering Committee, Psych Congress, walks clinicians through common medication interactions to be aware of as they develop treatment plans for patients with TD. In addition to highlighting which medications may increase the risk of TD development, Matthews underscores how clinicians can best navigate polypharmacy in a way that is safe, effective, and comfortable for patients. 

For more expert insights, visit the Tardive Dyskinesia Excellence Forum. 

For more conference coverage, visit the NP Institute newsroom. 

Desiree Matthews, PMHNP-BC: Hello, my name is Desiree Matthews and I'm a board-certified psychiatric nurse practitioner (NP). I'm owner and clinical director at Different MHP based out of Charlotte, North Carolina.

Psych Congress Network: In your experience, what are some common medication interactions that can exacerbate or contribute to the development of tardive dyskinesia, and how do you navigate these potential risks when managing patients with psychiatric disorders? 

Matthews: Let’s talk a little bit about what may increase our patient's risk of developing tardive dyskinesia. So, first and foremost, being on an antipsychotic, our typical antipsychotics have a greater risk of developing tardive dyskinesia. However, atypicals are still widely used and can certainly contribute to many cases of tardive dyskinesia. 

When I think about medications that I often see my patients on, I would say that anticholinergics are the biggest concern that I have because these medications can actually increase the patient's risk of developing tardive dyskinesia later on in life, and these anticholinergics are approved to be used for drug-induced Parkinsonism. However, they are not approved to be used for tardive dyskinesia. In fact, if a patient does develop tardive dyskinesia and they are added an anticholinergic or are on an anticholinergic, it actually may exacerbate the movements of tardive dyskinesia. So, anticholinergics should not be used for the treatment of tardive dyskinesia.

PCN: Could you discuss any strategies or considerations you implement when prescribing medications for patients with tardive dyskinesia to minimize the risk of adverse interactions or exacerbation of symptoms?  

Matthews: There are a few things to consider when you are going to treat tardive dyskinesia. First and foremost, we want to make sure that we're treating the correct condition. So again, looking at the onset of these abnormal movements, the quality or what they look like, as well as making sure you take a thorough history to see if they've been exposed to anything that blocks dopamine, like in psychiatry, our antipsychotics. 

Now, our patients don't live in a bubble, right? Many of these patients are on polypharmacy. They might be on blood pressure medications, HIV medications, anti-seizure medications, antidepressants. So, when choosing a vesicular monoamine transporter 2 (VMAT2) inhibitor, it's important to choose a medication in which there is minimal drug-to-drug interaction. Metabolic pathways are important, and the 2 VMAT inhibitors that we have, deutetrabenazine as well as valbenazine, do have different pathways in terms of metabolism. 

I would also consider when dosing VMAT2 inhibitors that we want to resolve the impact that tardive dyskinesia may have. So, one of the pitfalls I find with treating patients with tardive dyskinesia is that we may not be dosing our patients optimally. We want to make sure that we start at the recommended dosing for these medications but also keep in mind the medications may need to get to a higher dose to fully resolve the impact. 

It may be a little bit difficult to sometimes tell our patients that, “You're on a medication that gave you tardive dyskinesia, now we have to add another medication to help mitigate those symptoms or help resolve the impact that those movements are having.” It can be a difficult conversation to navigate. However, I do talk to my patients that TD is generally persistent, it is irreversible and really use motivational interviewing and a lot of education to help them understand how a VMAT2 inhibitor works.

Thank you for joining me here today. I hope these tips were helpful for your practice and I hope to see you again soon.

Desiree Matthews, PMHNP-BC, is a board certified psychiatric nurse practitioner with expertise in treating patients living with severe mental illness. Beyond clinical practice, Desiree has provided leadership in advocating for optimal outcomes of patients and elevating health care provider education. Desiree is the founder and owner of Different MHP, a telepsychiatry practice founded with the mission of providing affordable, accessible precision focused, integrative psychiatry to patients through a rich and comprehensive mentorship of the health care providers within the company.

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