Survey of Neurologists and Psychiatrists Reveals Barriers to Optimal Tetrabenazine Use

Results from an international physician survey suggested that although tetrabenazine (TBZ) remains a commonly used treatment for hyperkinetic movement disorders, its clinical utility may be limited by tolerability concerns that frequently prevent dose optimization.

The survey included physicians from Australia, Israel, and South Korea and evaluated clinicians’ experience with TBZ in real-world practice. In the study, neurologists and psychiatrists reported moderate overall satisfaction with TBZ when treating tardive dyskinesia (TD) and Huntington disease (HD)–related chorea, but many indicated that adverse effects (AEs) often interfere with achieving optimal therapeutic dosing.¹

Overall, 96 physicians participated, including neurologists managing HD-related chorea and neurologists and psychiatrists treating TD. Respondents collectively reported treating 195 patients with HD-related chorea and 1413 patients with TD. Study author Daniel Claassen, MD, MS, director of the Huntington’s Disease Clinic at Vanderbilt University Medical Center, noted that “although most physicians were somewhat satisfied with TBZ, substantial proportions reported that they were often or almost always unable to titrate TBZ to an optimal dose because of side effects.”¹

Treatment Patterns in Huntington Disease–Related Chorea

Among neurologists treating HD-related chorea, TBZ remained the most commonly used therapy, particularly in Australia and Israel. Approximately 83% of neurologists reported experience prescribing TBZ, yet they estimated that the drug was used in fewer than half of their patients.

Overall, physicians reported that 53% of patients with HD-related chorea had received TBZ within the previous two years, and 42% were actively receiving it at the time of the survey. Other treatments used in clinical practice included haloperidol, clonazepam, risperidone, amantadine, and other antipsychotic or antiepileptic agents.¹

Despite its widespread use, several barriers to TBZ therapy were identified. Neurologists reported that approximately 25% of patients could not be titrated to an optimal dose because of AEs. In addition, 15% of clinicians indicated that AEs often led to discontinuation of therapy.

Sedation and somnolence were the most commonly cited AEs limiting treatment escalation, followed by depression and suicidal ideation. These safety concerns also contributed to early discontinuation, with TBZ typically stopped approximately 4.3 months after initiation in patients who discontinued treatment.¹

Similar Challenges Observed in Tardive Dyskinesia

Parallel patterns were observed among physicians managing TD. Although 86% of neurologists and psychiatrists reported experience prescribing TBZ, clinicians estimated that only about 20% of their patients with TD were treated with the drug.

Among the 1413 patients with TD described in the survey, 30% had received TBZ during the prior two years and 18% remained on treatment when the survey was conducted. More common initial strategies included adjusting antipsychotic therapy, such as switching to a second-generation antipsychotic or modifying dosage.¹

Side effects again emerged as a major limitation. Approximately 18% of physicians reported that AEs frequently prevented titration to an optimal TBZ dose, while 24% stated that AEs often resulted in treatment discontinuation. The most commonly reported AEs included sedation, somnolence, anxiety, and depression. In addition, suicidal ideation was cited as a leading reason for discontinuing therapy in some patients with TD.¹

Satisfaction with TBZ in TD was generally modest: 61% of clinicians reported being moderately satisfied, while only 17% indicated they were very or extremely satisfied with treatment outcomes.

Impact on Quality of Life and Treatment Decisions

Physicians reported that symptom burden and quality-of-life impairment strongly influenced treatment decisions for both disorders.For patients with HD-related chorea, clinicians identified impaired gait or balance, social withdrawal, and difficulty concentrating as the most bothersome symptoms. Similarly, in TD, involuntary facial movements, swallowing difficulties, and speech impairment were perceived as major drivers of reduced quality of life.

Approximately 70% of physicians indicated that impairment in daily functioning or quality of life was among the top reasons for initiating treatment for both conditions.¹ However, the survey results suggest that tolerability concerns remain a key factor shaping treatment decisions.

REFERENCES
1. Sung VW, Claassen DO, Ribalov R, et al. Physician experience and perceptions of tetrabenazine for the treatment of tardive dyskinesia and Huntington’s chorea: a survey of neurologists and psychiatrists. Neurotherapeutics. 2026;26(2):197-205. doi: 10.1080/14737175.2025.2602188
2. Waln O, Jankovic J. An update on tardive dyskinesia: from phenomenology to treatment. Tremor Other Hyperkinet Mov (N Y). 2013;3:tre-03-161-4138-1. doi:10.7916/D8MG7M8C
3. Frank S. Treatment of Huntington disease. Neurotherapeutics. 2014;11(1):153-160. doi:10.1007/s13311-013-0244-z