Tardive dyskinesia

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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:

Incidence varies in series, but 31% (95% CI 20% - 42%) after 43 weeks of cumulative neuroleptic treatment in the elderly has been reported[5].

Treatment

LogoKeyPointsBox.pngA review in 2007 concludes there is no effective predictable treatment[6]
This is difficult, apart from drug withdrawal, which actually has little convincing evidence itself [7] as in 40% symptoms do not disappear within 5 years of drug withdrawal[8]. There is little evidence for anticholinergic drugs even though they are widely used, and indeed withdrawal of them can be beneficial ! [9]. There is some evidence for α-tocopherol protecting against deterioration of tardive dyskinesia but none that it improves symptoms[10]

QuotationMarkLeft.png A case of improvement of refractory tardive dyskinesia on α-tocopherol without relapse when it was discontinued after patient had a DVT suggests any benefit may not outweigh risk QuotationMarkRight.pngmlj

. Case reports exist for pallidotomy[11], but there is more evidence for bilateral deep brain stimulation of the globus pallidus[12]. A recent report claims benefit for zolpidem[13].

Unproved therapies include:

References

  1. Turner TH. Tardive dyskinesia. British medical journal (Clinical research ed.) 1988;296(6623):719.
  2. Woods SW, Morgenstern H, Saksa JR, Walsh BC, Sullivan MC, Money R, Hawkins KA, Gueorguieva RV, Glazer WM. Incidence of tardive dyskinesia with atypical versus conventional antipsychotic medications: a prospective cohort study. The Journal of clinical psychiatry. 2010 Feb 9.(Epub ahead of print) (Link to article – subscription may be required.)
  3. Tenback DE, van Harten PN, Slooff CJ, van Os J. Evidence that early extrapyramidal symptoms predict later tardive dyskinesia: a prospective analysis of 10,000 patients in the European Schizophrenia Outpatient Health Outcomes (SOHO) study. The American journal of psychiatry 2006;163(8):1438-40. (Direct link – subscription may be required.)
  4. Syu A, Ishiguro H, Inada T, Horiuchi Y, Tanaka S, Ishikawa M, Arai M, Itokawa M, Niizato K, Iritani S, Ozaki N, Takahashi M, Kakita A, Takahashi H, Nawa H, Keino-Masu K, Arikawa-Hirasawa E, Arinami T. Association of the HSPG2 Gene with Neuroleptic-Induced Tardive Dyskinesia. Neuropsychopharmacology : official publication of the American College of Neuropsychopharmacology. 2010 Jan 13.(Epub ahead of print) (Link to article – subscription may be required.)
  5. Saltz BL, Woerner MG, Kane JM, Lieberman JA, Alvir JM, Bergmann KJ, et al. Prospective study of tardive dyskinesia incidence in the elderly. JAMA : the journal of the American Medical Association 1991;266(17):2402-6.
  6. Soares-Weiser K, Fernandez HH. Tardive dyskinesia. Seminars in neurology 2007;27(2):159-69. (Direct link – subscription may be required.)
  7. a b c Soares-Weiser K, Rathbone J. Neuroleptic reduction and/or cessation and neuroleptics as specific treatments for tardive dyskinesia. Cochrane database of systematic reviews (Online) 2006;(1):CD000459.(Epub) (Direct link – subscription may be required.)
  8. Lenders MW, Buschman HP, Vergouwen MD, Steur EN, Kölling P, Hariz M. Long term results of unilateral posteroventral pallidotomy for antipsychotic drug induced tardive dyskinesia. Journal of neurology, neurosurgery, and psychiatry 2005;76(7):1039. (Direct link – subscription may be required.)
  9. Greil W, Haag H, Rossnagl G, Rüther E. Effect of anticholinergics on tardive dyskinesia. A controlled discontinuation study. The British journal of psychiatry : the journal of mental science 1984;145:304-10.
  10. Soares KV, McGrath JJ. Vitamin E for neuroleptic-induced tardive dyskinesia. Cochrane database of systematic reviews (Online) 2001;(4):CD000209.
  11. Lenders MW, Buschman HP, Vergouwen MD, Steur EN, Kölling P, Hariz M. Long term results of unilateral posteroventral pallidotomy for antipsychotic drug induced tardive dyskinesia. Journal of neurology, neurosurgery, and psychiatry 2005;76(7):1039. (Direct link – subscription may be required.)
  12. Damier P, Thobois S, Witjas T, Cuny E, Derost P, Raoul S, et al. Bilateral deep brain stimulation of the globus pallidus to treat tardive dyskinesia. Archives of general psychiatry 2007;64(2):170-6. (Direct link – subscription may be required.)
  13. Bishnoi M, Chopra K, Kulkarni SK. Possible anti-oxidant and neuroprotective mechanisms of zolpidem in attenuating typical anti-psychotic-induced orofacial dyskinesia-A biochemical and neurochemical study. Progress in neuro-psychopharmacology & biological psychiatry 2007;31(5):1130-8. (Direct link – subscription may be required.)
  14. Silver H, Geraisy N, Schwartz M. No difference in the effect of biperiden and amantadine on parkinsonian- and tardive dyskinesia-type involuntary movements: a double-blind crossover, placebo-controlled study in medicated chronic schizophrenic patients. The Journal of clinical psychiatry 1995;56(4):167-70.
  15. Bhoopathi PS, Soares-Weiser K. Benzodiazepines for neuroleptic-induced tardive dyskinesia. Cochrane database of systematic reviews (Online) 2006;3:CD000205.(Epub) (Direct link – subscription may be required.)
  16. Soares K, Rathbone J, Deeks J. Gamma-aminobutyric acid agonists for neuroleptic-induced tardive dyskinesia. Cochrane database of systematic reviews (Online) 2004;(4):CD000203.(Epub) (Direct link – subscription may be required.)
  17. Soares-Weiser K, Rathbone J. Calcium channel blockers for neuroleptic-induced tardive dyskinesia. Cochrane database of systematic reviews (Online) 2004;(1):CD000206. (Direct link – subscription may be required.)
  18. McGrath JJ, Soares KV. Miscellaneous treatments for neuroleptic-induced tardive dyskinesia. Cochrane database of systematic reviews (Online) 2000;(2):CD000208.
  19. Tammenmaa IA, McGrath JJ, Sailas E, Soares-Weiser K. Cholinergic medication for neuroleptic-induced tardive dyskinesia. Cochrane database of systematic reviews (Online) 2002;(3):CD000207.
  20. Bishnoi M, Chopra K, Kulkarni SK. Theophylline, adenosine receptor antagonist prevents behavioral, biochemical and neurochemical changes associated with an animal model of tardive dyskinesia. Pharmacol Rep. 2007;59(2):181-91.

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