5. VALBENAZINE TREATMENT FOR TARDIVE DYSKINESIA IN A 64-YEAR-OLD FEMALE PRESENTING WITH NONHEALING WOUNDS DUE TO TRUNCAL DYSKINESIA: A CASE REPORT

Abstract

Introduction

Tardive dyskinesia (TD) is a persistent and often debilitating hyperkinetic movement disorder associated with prolonged exposure to dopamine receptor blocking agents (DRBAs). Uncontrolled movements due to TD can cause additional burdens to patients, including difficulty swallowing and performing activities of daily living. Even in the approximately 25% of patients with TD who are unaware of their uncontrolled movements, quality of life for the patient, caregiver, and family can be negatively affected. Valbenazine is a highly selective vesicular monoamine transporter 2 (VMAT2) inhibitor, approved as a once-daily medication for the treatment of TD and chorea associated with Huntington’s Disease. In placebo-controlled trials and long-term studies, valbenazine has been shown to be safe and uniquely effective in treating TD. Here, we report the case of a patient who had severe wounds due to undiagnosed TD and was eventually treated with valbenazine for TD.

Methods

N/A

Results

In May 2022, a 64-year-old female patient presented with severe wounds on her lumbar spine. At presentation, the patient was taking 200 mg quetiapine, lowered from 300 mg two months prior, for type 1 bipolar disorder and had a GREATER THAN 10-year history of DRBA use. Standard of care wound treatment was initiated by her primary care provider; however, the wounds were not healing with repeated re-openings. In October 2022, assessment by a geriatrician and certified wound care specialist determined that the wounds were caused by sheer force from uncontrolled dyskinesia while sitting or lying in bed. Based on clinician assessment and medical history, the patient was diagnosed with TD. She was also evaluated using the Abnormal Involuntary Movement Scale (AIMS), a clinician-rated scale used to measure the severity of dyskinesia across 7 body regions. AIMS item scores range from 0 (“none”) to 4 (“severe”), and the AIMS total score (sum of items 1-7) range from 0 to 28. The patient had an AIMS total score of 12, with particularly severe movements in both the trunk (item score = 4) and lower extremities (item score = 4). The patient was resistant to her TD diagnosis, expressing a lack of awareness of her movements. She was provided a trial of 40 mg valbenazine samples to treat her TD, but did not take this medication due to her hesitancy/aversion to acknowledge the TD diagnosis. In April 2023 (6 months after TD diagnosis), the patient finally initiated treatment with 40 mg valbenazine. After assessment at 2 weeks, the patient had improved but was still experiencing uncontrolled movements, particularly in the trunk and lower extremities; thus, her valbenazine dose was increased to 60 mg. After 23 weeks of consistent treatment with valbenazine, the patient’s AIMS total score decreased by5points (AIMS total score=7), and she reported improvements in her daily functioning. The patient saw significant improvement in her TD symptoms, particularly in her truncal movements (item score = 1 [“minimal”]). Valbenazine was well tolerated by the patient, with no side effects reported after 23 weeks. The patient’s chronic wounds, which persisted for a total of 11 months prior to consistent valbenazine treatment, achieved complete closure after 5 months of valbenazine and standard of care wound treatment.

Conclusions

This case report highlights that TD may be an underlying cause for additional medical complications that appear unrelated to TD, even in patients who are unaware of their movements. Therefore, it is important for healthcare professionals in all fields to be educated on the diagnosis, assessment, and treatment of TD, including the stigma of the diagnosis, to provide safe and effective care for patients taking DRBAs especially those who are at risk for developing TD.