Tardive dyskinesia

From Ganfyd

A form of extrapyramidal disorder associated with exposure to dopamine depleting drugs such as neuroleptics. It may occur independent of such exposure rarely^[1]. It is characterised by orofacial dyskinesia although choreiform trunk and limb movements are usually included also within the definition of the syndrome. It is:

• More common and severe in the elderly
• Associations exist with drug induced parkinsonism^[2], acute akathisia and acute dystonia with these conditions perhaps preceding its onset.
• May be more likely to have early onset in unipolar and bipolar disorder
• May be more likely in negative symptom schizophrenia
• May have an association with hyperglycaemia

Incidence varies in series, but 31% (95% CI 20% - 42%) after 43 weeks of cumulative neuroleptic treatment in the elderly has been reported^[3].

Treatment

This is difficult, apart from drug withdrawal, which actually has little convincing evidence itself ^[5] as in 40% symptoms do not disappear within 5 years of drug withdrawal^[6]. There is little evidence for anticholinergic drugs even though they are widely used, and indeed withdrawal of them can be beneficial ! ^[7]. There is some evidence for α-tocopherol protecting against deterioration of tardive dyskinesia but none that it improves symptoms^[8] . Case reports exist for pallidotomy^[9], but there is more evidence for bilateral deep brain stimulation of the globus pallidus^[10]. A recent report claims benefit for zolpidem^[11].

Unproved therapies include:

• Dopamine agonists
• Biperiden and amantadine^[12]
• Benzodiazepines^[13]
• Gamma-aminobutyric acid (GABA) agonists^[14] such as baclofen, gamma-vinyl-GABA, gamma-acetylenic-GABA, progabide, muscimol, sodium valproate and tetrahydroisoxazolopyridine (THIP)
• Calcium-channel blockers such as diltiazem, nifedipine, nimodipine and verapamil^[15]
• Tiapride^[16]
• Celiprolol^[17]
• Low dose insulin, botulinium toxin, endorphin, oestrogen, essential fatty acids, ganglioside, lithium, naloxone, periactin, phenylalanine, piracetam, tryptophan, neurosurgery, or ECT^[18]
• Cholinergic drugs ^[19] such as choline, lecithin, physostigmine, tacrine, galantamine, donepezil, rivastigmine or cevimeline.
• Theophylline except in animal models of adenosinergic receptor system dysfunction^[20]

References

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