VMAT2 Inhibitors for Tardive Dyskinesia

[QofQuimica]

Curious if anyone here has experience with prescribing or using these (valbenazine or deutetrabenazine). Do you find that they work well in practice? Any issues with prolonged QTc or 2D6 interactions?

The deuterated one....just blows my mind. What an amazing idea.

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[DisorderedDoc417]

It’s a nice mask. It’s expensive. When you take it away, the TD comes back, sometimes worse than what you started with. For some people this may have a niche.

 

[PikminOC]

Is this a sponsored ad for these meds? Seems weird.

 

[Sushirolls]

I've seen tetrabenazine in HD population, good results in earlier stages. Tried to get ~2 patients with TD on tetrabenazine before the new one came out, but because it was inpatient, and a sea of paperwork, I never got the medicine connected to the patient during my watch while they were on the inpatient unit. I've not seen the Valbenazine in action, but if I have a TD patient with quality of life impairment, I will attempt to prescribe.

 

[whopper]

I've prescribed it and have an N of 1.

Total success. No side effects. I prescribed the generic older one (forgot which one's the generic and which one's the newer tradename).

I don't see TD much these days. The pt I had who had TD, the guy's idiot prior psychiatrist put him on Haldol > 20 mg a day and the pt developed TD and instead of getting him off of the Haldol the idiot upped the dose, never explained to him he had TD, and whenever he mentioned he had a problem the psychiatrist just ignored him.

 

[QofQuimica]

Is this a sponsored ad for these meds? Seems weird.

This is me asking a question because I’m not a psychiatrist and will never prescribe these meds, but I’m interested in drug pharmacology and toxicology. Not sure why that seems like an ad to you, but no, I have no vested interest in your prescription habits.

I've prescribed it and have an N of 1.

Total success. No side effects. I prescribed the generic older one (forgot which one's the generic and which one's the newer tradename).

I don't see TD much these days. The pt I had who had TD, the guy's idiot prior psychiatrist put him on Haldol > 20 mg a day and the pt developed TD and instead of getting him off of the Haldol the idiot upped the dose, never explained to him he had TD, and whenever he mentioned he had a problem the psychiatrist just ignored him.

Tetrabenazine is the old generic (Nondeuterated). From what I’ve read, it was never approved in this country for TD but I guess people probably use it off-label? Both of the ones I mentioned were approved in 2017 so I’m guessing they are not generic.

 

[clausewitz2]

This is me asking a question because I’m not a psychiatrist and will never prescribe these meds, but I’m interested in drug pharmacology and toxicology. Not sure why that seems like an ad to you, but no, I have no vested interest in your prescription habits.


Tetrabenazine is the old generic (Nondeuterated). From what I’ve read, it was never approved in this country for TD but I guess people probably use it off-label? Both of the ones I mentioned were approved in 2017 so I’m guessing they are not generic.

Tetrabenazine had a very long history in psychiatry as an agent noted to be effective for treating TD. Its use was limited by a) failure of anyone to pursue getting an indication for that for it b) psychiatry's tendency to just forget about drugs that are not currently being pushed by pharmaceutical companies c) clinical lore is many people got crushingly depressed with it so it was not super widely used.

The new agents are as you note still very new and very expensive. Remains to see if the SE of tetrabenazine are noted with these agents, a bit too early to tell.

As far as pharmacology is concerned, we just recently had a thread pondering why these things work for TD if the dopamine receptor upregulation hypothesis of TD is correct and whether it supports the idea of actually increasing dopamine blockade to treat it. I think it is fair to say disagreement was spirited.

 

[thoffen]

Increasing dopamine blockade might be a short term benefit.

But anyway I do have experience with a couple of patients but they were referred to our movement disorders clinic and have to get it through specialty pharmacy and I'm glad not to have to try and navigate getting prior authorization through insurance too. My patients have had quite a significant improvement but by no means resolution. For the right patient, that can be life altering. For one in particular it has significantly affected her social anxiety and caused much more willingness to engage with others and made a big impact on that front. Ideally, since dx is BPAD, she might have been kept from developing TD in the first place, but that wasn't on my plate. I do realize I'm not great about formal AIMS exams and checking tone every time but I do try to pay attention to it.

 

[whopper]

but I guess people probably use it off-label?

Yes. It goes to show you how much of our field is commercial-driven. Tetrabenazine was the med that could work well but hardly any psychiatrists knew about it. Then all of a sudden the newer FDA-approved, expensive through the roof med comes out and all of a sudden everyone knows about both of them.

 

[st2205]

Yes. It goes to show you how much of our field is commercial-driven. Tetrabenazine was the med that could work well but hardly any psychiatrists knew about it. Then all of a sudden the newer FDA-approved, expensive through the roof med comes out and all of a sudden everyone knows about both of them.

Tetrabenazine itself is too expensive. Almost $1k/month. WTF not reserpine? $20/month. Nobody ever talks about that.

Also, you need an FDA indication to endow substances with healing properties. The FDA gathers together and does it by the laying on of hands. Dangerous stuff prescribing stuff off label, because the FDA hasn’t given it the power to be effective.

 

[clausewitz2]

Tetrabenazine itself is too expensive. Almost $1k/month. WTF not reserpine? $20/month. Nobody ever talks about that.

Also, you need an FDA indication to endow substances with healing properties. The FDA gathers together and does it by the laying on of hands. Dangerous stuff prescribing stuff off label, because the FDA hasn’t given it the power to be effective.

Good point on reserpine. It also handily has antipsychotic properties that everyone always forgets about and close examination of the clinical lore suggests that the depression it is reputed to cause is actually something like akathisia, which, y'know, neuroleptics are also wont to cause.