Persistent tardive dyskinesia: demographic and pharmacological risk factors

First generation antipsychotic-associated serious adverse events in women: a retrospective analysis of a pharmacovigilance database

BACKGROUND

Women have been under-represented in trials of antipsychotic medications.

AIM

Our primary objective was to evaluate five adverse events (AE) associated with first-generation antipsychotics (FGAs) among women relative to men through an analysis of the FDA Adverse Event Reporting System (FAERS).

METHOD

We queried 24.6 million AE reports from 2000 to 2023 involving FGAs. The study cohort consisted of chlorpromazine (n = 3317), fluphenazine (n = 1124), haloperidol (n = 16,709), loxapine (n = 3151), perphenazine (n = 816), thioridazine (n = 665), thiothixene (n = 244), and trifluoperazine (n = 360). Cases of neuroleptic malignant syndrome (NMS), tardive dyskinesia (TD), Torsades de Pointes (TdP), agranulocytosis (AG), and cerebrovascular adverse events (CVAE) were identified. Reporting odds ratios (ROR) and associated 95% confidence intervals (CI) were calculated with logistic regression for each AE among women relative to men.

RESULTS

A total of 2,857 serious AEs were evaluated in the study cohort (NMS = 1810, TD = 434, TdP = 260, AG = 149, CVAE = 204). The ROR for women compared to men was 0.79 (95% CI, 0.71-0.87) for NMS, 0.83 (0.68-1.01) for TD, 1.21 (0.94-1.53) for TdP, 0.71 (0.51-0.98) for AG, and 0.91 (0.68-1.19) for CVAE. A secondary analysis revealed a higher odds in women compared to men of hospitalization associated with reports of TD (ROR = 1.95, 1.29-2.94) and death associated with reports of AG (ROR = 2.46, 1.15-5.24). A subgroup analysis of haloperidol revealed an ROR = 1.67 (1.26-2.21) for women relative to men for TdP.

CONCLUSION

The subgroup analysis of haloperidol AEs revealed a significantly higher reporting odds ratio for TdP. Additionally, the secondary study findings suggest that women were more vulnerable to worse outcomes associated with certain AEs of FGAs.

Tardive Dyskinesia Following Low-Dose Risperidone

Tardive dyskinesia is an involuntary athetoid or choreiform movement lasting a minimum of a few weeks. It is associated with the use of neuroleptic medication for at least three months and persists beyond four to eight weeks. Tardive dyskinesia usually occurs as a result of the long-term use of dopamine receptor-blocking agents, mainly first-generation antipsychotics or a high-dose, second-generation antipsychotic. We present a case of a 28-year-old female with osteogenesis imperfecta presented later with major depressive disorder with psychotic features. She was given a low-dose second-generation antipsychotic, namely, risperidone (2 mg) for psychosis for a cumulative duration of three months. As a result, she developed extrapyramidal symptoms in the form of akathisia, axial dystonia, involuntary movement of the right hand, and smacking movement of the lips. Symptoms persisted for more than eight weeks despite discontinuing risperidone and switching to quetiapine. After the exclusion of other differential diagnoses, she was labeled as a case of tardive dyskinesia. More studies are needed to assess whether undiscovered contributing factors to tardive dyskinesia exist and to understand how second-generation antipsychotics (SGAs) contribute to the development of tardive dyskinesia.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Gastroparesis, metoclopramide, and tardive dyskinesia: Risk revisited

BACKGROUND

Metoclopramide is primarily a dopamine receptor antagonist, with 5HT₃ receptor antagonist and 5HT₄ receptor agonist activity, and used as an antiemetic and gastroprokinetic since almost 50 years. Regulatory authorities issued restrictions and recommendations regarding long-term use of the drug at oral doses exceeding 10 mg 3-4 times daily because of the risk for development of tardive dyskinesia. The aim of our study was to review mechanism(s) of action and pharmacokinetic-pharmacodynamic properties of metoclopramide, as well as the risk of metoclopramide-induced tardive dyskinesia, factors that may change drug exposure in humans, and to summarize the clinical context for appropriate use of the drug.

METHODS

A PubMed, Google Scholar, and Cross Reference search was done using the key words and combined searches: drug-drug interaction, gastroparesis, metoclopramide, natural history, pharmacokinetics, pharmacodynamics, drug-drug interaction, outcome, risk factors, tardive dyskinesia.

KEY RESULTS

Data show that the risk of tardive dyskinesia from metoclopramide is low, in the range of 0.1% per 1000 patient years. This is far below a previously estimated 1%-10% risk suggested in treatment guidelines by regulatory authorities. High-risk groups are elderly females, diabetics, patients with liver or kidney failure, and patients with concomitant antipsychotic drug therapy, which reduces the threshold for neurological complications.

CONCLUSIONS & INFERENCES

The risk of tardive dyskinesia due to metoclopramide is far below approximated numbers in treatment guidelines. This risk and the influence of known risk factors should be considered when starting a course of metoclopramide for treatment of gastroparesis.

Tardive dyskinesia update: the syndrome

Tardive dyskinesia is a common iatrogenic neurological and neurobehavioural syndrome associated with the use of antidopaminergic medication, especially antipsychotics. Prior to the introduction of the newer antipsychotics in the 1990s, it was one of the major areas of psychiatric research but interest waned as the new drugs were reputed to have a reduced liability to extrapyramidal adverse effects in general, a claim now discredited by numerous pragmatic research studies. Early small-scale short-term prevalence studies were presented as evidence to support the assumption that patients on the newer drugs did indeed have a lower prevalence of tardive dyskinesia but recent large-scale review of studies with patients exposed for longer suggest that things have not changed. This article presents a clinical overview of a complex and varied syndrome in terms of its phenomenology, epidemiology and risk factors; a companion article will consider treatment. This overview aims to highlight tardive dyskinesia once again, especially to practitioners who have trained in an environment where this was considered mainly in historical terms.

LEARNING OBJECTIVES

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DECLARATION OF INTEREST

None.

The current prevalence and factors associated with tardive dyskinesia among Filipino schizophrenic patients

OBJECTIVE

To determine the prevalence of and the factors associated with tardive dyskinesia (TD) among Filipino patients with schizophrenia admitted at the National Center for Mental Health.

STUDY DESIGN

Cross-sectional study.

METHODS

A total of 227 inpatients fulfilling the DSM-IV TR criteria for schizophrenia participated in the study. Demographic data including age, disease duration and medication intake were obtained. The Abnormal Involuntary Movement Scale (AIMS) and Simpson Angus Rating Scale (SARS) were performed on all patients. Odds of developing TD in relation to the different variables were computed. The association between study variables and development of TD was also evaluated using the Chi-square test.

FINDINGS

Our cohort of patients had a mean age of 40 (range: 19-73 years old), had a mean disease duration of 6 years, had a daily neuroleptic dose of 700 mg in chlorpromazine equivalent, and had a lifetime neuroleptic exposure of at least 5 years. The prevalence rate of TD was 20.3% (46 out of 227 patients). Fifty-three percent of patients had significant extrapyramidal features (SARS > or =3). TD was noted more in females and older age groups. The other factors associated with TD: were those patients with longer duration of illness and those patients with longer cumulative exposure to neuroleptic drugs. There was no association found with regard to the presence of diabetes mellitus type II, to the use of anticholinergic drugs, to the history of substance abuse and to the history of electroconvulsive therapy.

CONCLUSIONS

Despite the predominant use of first-generation antipsychotic agents, the prevalence of TD among Filipino schizophrenic patients is similar to that reported among Asians, but lower than that reported among our Western counterparts. The results may be affected by differences in methodological, racial and genetic determinants.

Orofacial movement disorders

This article reviews three poorly recognized yet relatively common presentations of hyperactive orofacial movement disorders: oromandibular dystonia, orofacial dyskinesia, and drug-induced extrapyramidal syndrome reactions. Orofacial movement disorders are often misdiagnosed as temporomandibular disorders, hence understanding these conditions is pertinent for the practitioner treating orofacial pain. Aspects of epidemiology, etiology, pathophysiology, clinical presentation, and diagnosis are discussed along with treatment considerations for these orofacial movement disorders.

Tardive dyskinesia in Chinese inpatients with chronic schizophrenia

The objective of the study was to determine the point prevalence of tardive dyskinesia (TD) in Chinese inpatients with chronic schizophrenia and its association with sociodemographic, clinical and treatment variables and other movement disorders. A cross-sectional assessment of a randomly selected cohort of inpatients (n=225; mean age=42+/-7 years) with DSM-IV schizophrenia was employed using standard rating instruments for TD and other drug-induced movement disorders, in addition to catatonia, and psychotic, negative, depressive and obsessive-compulsive symptoms. Using Schooler and Kane's criteria, 15 subjects (6.7%) had TD. Patients with TD were significantly older and significantly fewer of them were taking antiparkinsonian medication than subjects without TD. There was no significant difference between the TD and non-TD groups with respect to other demographic, clinical and treatment variables including sex, age of onset, length of contact with psychiatric services, current antipsychotic dosage, negative symptoms, catatonia and parkinsonism. The results confirmed the low prevalence of TD in patients with chronic schizophrenia compared to those found in Caucasian patients. The study has also replicated the association of TD in Chinese schizophrenia patients with older age but failed to demonstrate any association between TD and other demographic or clinical characteristics including catatonia.

Classification and treatment of tardive syndromes

BACKGROUND

Tardive syndromes are a group of delayed-onset abnormal involuntary movement disorders induced by a dopamine receptor blocking agent. There are several phenomenologically distinct types of TS.

REVIEW SUMMARY

The term tardive dyskinesia has been used to refer to the TS that presents with rapid, repetitive, stereotypic movements mostly involving the oral, buccal, and lingual areas. Tardive dystonia can be focal, segmental, or generalized. It commonly affects the face and neck followed by the arms and trunk. It usually results in retrocollis when it involves the neck and trunk arching backwards when it involves the trunk. Tardive akathisia is characterized by a feeling of inner restlessness and jitteriness with an inability to sit or stand still. Other tardive syndromes include tardive tics, myoclonus, tremor, and withdrawal-emergent syndrome. It remains unclear whether tardive parkinsonism truly exists. The only way to prevent TS is to avoid its etiologic agents. Chronic use of dopamine receptor blocking agents should be limited as much as possible to patients with chronic psychoses. In general, for mild TS, reducing the neuroleptic dose, switching to an atypical agent, or discontinuing antipsychotic treatment altogether in the hope of facilitating remission is recommended. For moderate to severe TS, tetrabenazine or reserpine may be the most effective agent. Neuroleptics should be resumed to treat TD in the absence of active psychosis only as a last resort for persistent, disabling, and treatment-resistant TD.

CONCLUSIONS

The severity of the TS and the absolute need for antipsychotic therapy often dictate the treatment approach for this disorder.

The vacuous chewing movement (VCM) model of tardive dyskinesia revisited: is there a relationship to dopamine D(2) receptor occupancy?

Tardive dyskinesia (TD) is a late side effect of long-term antipsychotic use in humans, and the vacuous chewing movement (VCM) model has been used routinely to study this movement disorder in rats. Recent receptor occupancy studies in humans and rats have found that antipsychotics given in doses which lead to moderate levels of D(2) receptor blockade can achieve optimal clinical response while minimizing the emergence of acute motor side effects. This suggests that clinicians may have been using inappropriately high doses of antipsychotics. A review of the existing VCM literature indicates that most animal studies have similarly employed antipsychotic doses that are high, i.e. doses that lead to near complete D(2) receptor saturation. To verify whether the incidence or severity of VCMs would decrease with lower antipsychotic doses, we conducted initial experiments with different doses of haloperidol (HAL) given either as repeated daily injections or as depot injections over the course of several weeks. Our results demonstrate that (1) the incidence of VCMs is significantly related to HAL dose, and (2) significant levels of VCMs only emerge when haloperidol is continually present. These findings are consistent with the possibility that total D(2) occupancy, as well as 'transience' of receptor occupation, may be important in the development of late-onset antipsychotic-induced dyskinetic syndromes.

Treatment predictors of extrapyramidal side effects in patients with tardive dyskinesia: results from Veterans Affairs Cooperative Study 394

Predictors for the development of tardive dyskinesia (TD) have been studied extensively over the years, yet there are few studies of predictors of the course of TD after it has developed. Moreover, few studies have examined predictors of the course of other extrapyramidal side effects (EPS) in patients maintained on neuroleptics. The purpose of this study was to determine which modifiable variables are important in the prediction of EPS in patients with persistent TD over a period of as long as 2 years. One hundred fifty-eight patients enrolled in the Veterans Affairs Cooperative Study 394 were included in this study. A linear mixed-effects (LME) analysis to estimate the Abnormal Involuntary Movement Scale score (for TD severity), Simpson-Angus Scale (for parkinsonism severity), and Barnes Akathisia Scale at any given time after intake assessment was performed. The severity of each of the TD and EPS outcomes at any given visit was predicted by their respective baseline severity scores. Additional predictors of a favorable course of TD included lower doses of antipsychotic medications and use of anticholinergic medications. Other predictors of a favorable course of EPS included younger age and the use of atypical antipsychotic medication (for rigidity) and the use of anticholinergic medication (for tremor). These findings indicate that clinician-modifiable factors related to medication usage can influence the outcome of TD and EPS in patients with persistent TD.

Tardive dyskinesia among Chinese and Malay patients with schizophrenia

The prevalence of tardive dyskinesia (TD) was studied with the Abnormal Involuntary Movements Scale in Chinese and Malay patients with schizophrenia who were hospitalized in a Singapore state psychiatric institute. We also studied the relationship of neuroleptic-induced extrapyramidal side effects to TD. By using established criteria, the rates of TD were 40.6% for Chinese and 29.0% for Malays, higher than previously reported for Chinese subjects. Older age and lower current neuroleptic dose were significantly associated with TD. Multivariate analysis, after controlling for other salient risk variables, did not show a significant difference in TD prevalence rates between the two races. We conclude that suggested differences in interethnic rates of TD among Chinese, Malays, and Westerners are unlikely to exist and that any variation in prevalence is more likely to be determined by differences in duration of exposure and dose levels of neuroleptic drugs.

Extrapyramidal syndromes in neuroleptic-treated patients: prevalence, risk factors, and association with tardive dyskinesia

Prevalence and risk factors for extrapyramidal syndromes (EPS) were investigated in a sample of 1,559 patients. The overall prevalence of EPS was 29.4% (N = 458). Among the EPS-diagnosed patients, parkinsonism as assessed by the presence of core parkinsonian symptoms (rigidity, tremor, bradykinesia) was present in 65.9% of patients (N = 302), akathisia in 31.8% (N = 145), and acute dystonia in 2.1% (N = 10). Old age and long-term neuroleptic drug (NL) treatment were significantly associated with EPS in both the univariate and the multivariate analyses, whereas no relationship was observed with average NL daily doses and current NL treatment. EPS was diagnosed in 50.2% of 285 patients with persistent tardive dyskinesia (TD). Distribution of EPS in patients with TD showed that tremor and akathisia were more frequent in peripheral TD cases than in orofacial TD cases. Furthermore, there was a stronger association of NL-induced parkinsonism with peripheral TD than with orofacial TD. This study suggests that the association between EPS and TD may be limited to specific subtypes of TD. Peripheral TD showed a higher association with parkinsonism and with akathisia, suggesting that these symptoms may share a common pathophysiology.

Adolescents on neuroleptic medication: is this population at risk for tardive dyskinesia?

OBJECTIVE

The assess the incidence of tardive dyskinesia (TD) in a sample of adolescents treated with neuroleptic medication and to identify the presence of any risk factors for TD within the affected group.

METHOD

A retrospective chart review was conducted for 40 cases. The Abnormal Involuntary Movement Scale (AIMS) was used to measure side effects from medication at 6-month intervals over 2 years. Drug exposure was converted to chlorpromazine (CPZ) equivalent and the presence of risk factory for TD, such as a diagnosis of affective disorder, medication noncompliance, early age of illness onset, and concomitant antiparkinsonian medication, was also noted.

RESULTS

Of the 40 cases reviewed, 2 patients (5%) met diagnostic criteria for TD, and another 5 patients (12.5%) showed symptoms of TD.

CONCLUSIONS

TD is a serious risk at any age. Medication noncompliance, early age of illness onset, and concomitant use of antiparkinsonian medication may increase susceptibility to TD and should be carefully monitored.

Managing antipsychotic-induced acute and tardive dystonia

Antipsychotic-induced extrapyramidal adverse effects continue to be a serious problem in the treatment of psychotic disorders. While the pathophysiology of these adverse effects is not well understood, much recent research has focused on improving our ability to use available pharmacotherapy in the most effective and least toxic manner. Acute dystonic reactions only occur within the first days of antipsychotic treatment. They are often distressing and frightening for the patient and may even be dangerous. However, they can be effectively prevented or reversed with anticholinergics. Furthermore, the growing use of the new atypical antipsychotics will lead to a significant decrease in the rate of acute dystonic reactions. In contrast, tardive dystonia is a long-lasting menace in the course of antipsychotic treatment, for which there is no established therapy. Tardive dystonia is sometimes disabling or disfiguring and, like other tardive disorders, is potentially irreversible. Because, in most cases, patients need to continue taking the antipsychotic that has caused the adverse effect to prevent relapse of the mental illness, preventive measures are crucial. Antipsychotics should be prescribed only for patients affected by psychotic disorders, when definitely indicated and at the lowest effective dosage. The use of clozapine and other novel antipsychotic agents is also likely to represent an important step in the prevention and treatment of tardive dystonia. Compared with traditional antipsychotics, most of the new antipsychotics are characterised by a low acute extrapyramidal adverse effects liability and they also bring the hope of reducing the risk of tardive disorders. If tardive dystonia has occurred, switching to clozapine or another atypical antipsychotic and treatment with tetrabenazine, reserpine and botulinum toxin are possible options.

Postpartum mood disorders: clinical perspectives

Mood disorders are common in women. A prepregnancy personal history of mood disorder (bipolar or major depression), premenstrual syndrome, or (possibly) postpartum blues places a woman at high risk for a postpartum exacerbation of symptoms. Untreated or unrecognized postpartum mood disorders can lead to serious psychologic and social consequences, in some cases even leading to suicide or infanticide. Women at risk for postpartum mood disorders need to be referred for psychiatric consultation before pregnancy and parturition. Informed, professional collaboration offers the best opportunities for prevention, as well as the earliest recognition and treatment of emergent symptoms.

The relationship between motor effects in rats following acute and chronic haloperidol treatment

Tardive dyskinesia (TD) is a serious and sometimes irreversible side-effect to long-term neuroleptic treatment. In order to find predictors for development of TD, it would be of interest to known whether susceptibility to develop acute side-effects increases the risk of TD development. The study investigated in female Sprague-Dawley rats the relationship between haloperidol-induced acute motor effects, assessed by means of the grid test and the open field test, and the chronic motor effect assessed as vacuous chewing movements (VCM). The doses of haloperidol were 1.2, 2.4 and 4.8 mg/kg IP in the acute experiments and haloperidol decanoate 38 mg/kg per 4 weeks IM in the chronic experiment. The VCM obtained at different timepoints during the 24 weeks of chronic treatment were highly correlated. However, no correlation was found between the motor effects in the acute and the chronic experiments. The study does not indicate any connection between susceptibility to acute side-effects on neuroleptics and later development of TD.

Basal ganglia abnormalities in tardive dyskinesia. Possible relationship with duration of neuroleptic treatment

The purpose of the present study was to investigate CT abnormalities in tardive dyskinesia (TD) and to search for possible relationships with clinical data. A group of 30 psychotic patients (15 schizophrenic and 15 affective disorder) with TD was compared to a matched group of 30 psychiatric patients without TD and a matched group of 30 healthy controls. CT data were analyzed using two multivariate statistical methods [multidimensional scaling (MDS) and step-wise discriminant analysis]. MDS clearly separated both TD and non-TD groups from the healthy control group on the basis of CT parameters. Caudate left area reduction and left temporal sulci enlargement were the most important parameters that discriminated TD from non-TD patients. Only in TD-patients did caudate left area reduction and left temporal sulci enlargement correlate significantly with cumulative duration of psychiatric hospitalizations. The data of the present study support the findings of structural abnormalities in the caudate nucleus and in the temporal lobe of patients with TD. These abnormalities were especially marked in the left hemisphere. It is assumed that some factor related to longer psychiatric hospital treatment (e.g. neuroleptic intake) could account for these abnormalities.