The identification and careful management of modifiable risk factors in patients receiving antipsychotics are vital in preventing or minimizing the impact of tardive dyskinesia (TD). Our featured expert underscores the importance of a personalized approach when addressing these risk factors.

The risk of developing TD is heavily influenced by both the type and the dosage of antipsychotic medications. When we look at the type of medication, typical antipsychotics pose the highest risk, by far. There is some variability among the atypical antipsychotic medications, with lower-potency atypicals generally carrying a lower risk of developing TD. If an antipsychotic has induced acute symptomatology, such as an acute dystonic reaction or akathisia early in the course of treatment, it is more likely to induce TD. In addition, the use of anticholinergic medications has emerged as another risk factor for developing TD. Regarding the dosage, the higher the dose and the longer the duration of use, the greater the risk of TD.

There are also demographic and lifestyle factors that increase the risk of TD. For example, being over the age of 45 years, being a woman, and using antipsychotics to treat mood disorders rather than psychotic disorders all increase the risk. Additionally, obesity, diabetes—especially type 2 diabetes—and smoking have all emerged as significant contributors to the risk of TD.

Some risk factors are modifiable. The “low-hanging fruit” factors are the modifiable factors that are easier to address, including reducing the dose of the antipsychotic (if possible), switching to a lower-risk medication (if appropriate), and discontinuing unnecessary anticholinergic drugs. These are changes that we can make without much difficulty, and they can significantly reduce a patient’s risk of TD. Then we have the “mid-hanging fruit” factors, which are a bit more challenging to address but still manageable and include lifestyle changes such as reducing smoking and alcohol use. Finally, the “high-hanging fruit” factors are difficult to change (ie, reducing body mass index) or impossible to change (ie, aging).

If it is appropriate and necessary to use an antipsychotic with a higher risk of TD, it is crucially necessary to get informed consent from the patient, discussing both the risks and benefits. It is also important to ensure that baseline evaluations, such as the Abnormal Involuntary Movement Scale (AIMS), are used before starting treatment. Regular evaluations for movement disorders are important to catch any early signs of TD and adjust the treatment accordingly. If TD symptoms do emerge, patients are offered concurrent treatment with a US Food and Drug Administration (FDA)–approved VMAT2 inhibitor.

Finally, all patients have at least some risk of developing TD, so this is not an issue of a patient having no risk vs some risk. Instead, it is about understanding where on the spectrum of risk a patient falls and if we can move them toward the lower end of that spectrum.