Dosing & Uses
Dosage Forms & Strengths
tablet
- 12.5mg
- 25mg
Huntington Disease
Indicated for treatment of chorea associated with Huntington’s disease
Individualize and slowly titrate dosage over several weeks to identify a dose that reduces chorea and is well tolerated
Total daily dose up to 50 mg/day
- 12.5 mg PO qDay initially; after 1 week, the dose should be increased to 12.5 mg q12hr
- Maintenance: Titrate slowly by weekly intervals of 12.5 mg/day to identify dose that reduces chorea and is tolerated
- If daily dose is 37.5 to 50 mg/day, administer in divided doses q8hr
- Not to exceed 25 mg per single dose for total daily dosage between 37.5-50 mg/day
Total Daily dose >50 mg/day
- If >50 mg/day is required, test and genotype to determine if poor or extensive metabolizers of CYP2D6; not to exceed 100 mg/day or 37.5 mg/dose
- Dose maintenance requirements are dependent on CYP2D6 genotype (see Dosage Modifications)
Dosage Modifications
CYP2D6 extensive/intermediate metabolizers
- Extensive metabolizers may require dose >50 mg/day
- If total daily dose >50 mg/day, administer in divided doses q8hr
- Titrate slowly by 12.5 mg/day qWeek to identify dose that reduces chorea and is tolerated
- If >50 mg/day is required, do not to exceed 37.5 mg per single dose or a total daily dose of 100 mg/day
CYP2D6 poor metabolizers
- Not to exceed 25 mg per single dose or a total daily dose of 50 mg/day
Hepatic impairment
- Contraindicated; it is not possible to adjust the dose to ensure safe use
Dosing Considerations
May take with or without food
Dosage interruption >5 days: Retitrate dose when treatment resumed
Dosage interruption <5 days: May resume at previous maintenance dose without titration
Suspend upward dosage titration and reduce dose; discontinue if adverse reaction (intolerable effects such as: akathisia, restlessness, parkinsonism, insomnia, depression, suicidality, anxiety, sedation) does not resolve (may stop without taper)
Treatment discontinuation
- May discontinue without tapering
- Chorea may re-emerge within 12-18 hr after last dose
Tardive Dyskinesia (Off-label)
Investigational (see www.clinicaltrials.gov)
Safety and efficacy not established
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (12)
- deutetrabenazine
tetrabenazine, deutetrabenazine. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Do not use these drugs concomitantly. Deutetrabenazine may be initiated the day after discontinuing tetrabenazine.
- goserelin
goserelin increases toxicity of tetrabenazine by QTc interval. Contraindicated. Increases risk of torsades de pointes.
- isocarboxazid
tetrabenazine, isocarboxazid. Other (see comment). Contraindicated. Comment: Risk of acute hypertensive episode; separate by 14 d. Mechanism: MAOI causes accumulation of NE in neuron and tetrabenazine stimulates NE release.
- leuprolide
leuprolide increases toxicity of tetrabenazine by QTc interval. Contraindicated. Increases risk of torsades de pointes.
- linezolid
tetrabenazine, linezolid. Other (see comment). Contraindicated. Comment: Risk of acute hypertensive episode; separate by 14 d. Mechanism: MAOI causes accumulation of NE in neuron and tetrabenazine stimulates NE release.
- phenelzine
tetrabenazine, phenelzine. Other (see comment). Contraindicated. Comment: Risk of acute hypertensive episode; separate by 14 d. Mechanism: MAOI causes accumulation of NE in neuron and tetrabenazine stimulates NE release.
- procarbazine
tetrabenazine, procarbazine. Other (see comment). Contraindicated. Comment: Risk of acute hypertensive episode; separate by 14 d. Mechanism: MAOI causes accumulation of NE in neuron and tetrabenazine stimulates NE release.
- rasagiline
tetrabenazine, rasagiline. Other (see comment). Contraindicated. Comment: Risk of acute hypertensive episode; separate by 14 d. .
- selegiline
tetrabenazine, selegiline. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Risk of acute hypertensive episode; separate by 14 days. Mechanism: MAOI causes accumulation of norepinephrine in neuron and tetrabenazine stimulates norepinephrine release.
- selegiline transdermal
tetrabenazine increases effects of selegiline transdermal by pharmacodynamic synergism. Contraindicated. Risk of acute hypertensive episode; separate by 14 days. Mechanism: MAOI causes accumulation of NE in neuron and tetrabenazine stimulates NE release.
- tranylcypromine
tetrabenazine, tranylcypromine. Other (see comment). Contraindicated. Comment: Risk of acute hypertensive episode; separate by 14 d. Mechanism: MAOI causes accumulation of NE in neuron and tetrabenazine stimulates NE release.
- valbenazine
tetrabenazine, valbenazine. Either increases effects of the other by pharmacodynamic synergism. Contraindicated. Do not use these drugs concomitantly.
Serious - Use Alternative (49)
- alfuzosin
alfuzosin and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- amisulpride
amisulpride and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. ECG monitoring is recommended if coadministered.
- apomorphine
apomorphine and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- aripiprazole
aripiprazole and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- artemether
artemether and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- atomoxetine
atomoxetine and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- bedaquiline
bedaquiline and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- ceritinib
ceritinib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- citalopram
citalopram and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- clarithromycin
clarithromycin and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- clozapine
clozapine and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- crizotinib
crizotinib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- dasatinib
dasatinib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- degarelix
degarelix and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- desflurane
desflurane and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- dofetilide
dofetilide increases toxicity of tetrabenazine by QTc interval. Avoid or Use Alternate Drug.
- dolasetron
dolasetron and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- donepezil
donepezil and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- efavirenz
efavirenz and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- encorafenib
encorafenib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. Encorafenib is associated with dose-dependent QTc interval prolongation. Avoid with drugs known to prolong QT interval.
- entrectinib
tetrabenazine and entrectinib both increase QTc interval. Avoid or Use Alternate Drug.
- eribulin
eribulin and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. Potential for enhanced QTc-prolonging effects; if concurrent use is necessary then ECG monitoring is recommended.
- escitalopram
escitalopram increases toxicity of tetrabenazine by QTc interval. Avoid or Use Alternate Drug.
- fexinidazole
fexinidazole and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. Avoid coadministration of fexinidazole with drugs known to block potassium channels and/or prolong QT interval.
- fingolimod
fingolimod and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- gilteritinib
gilteritinib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- glasdegib
tetrabenazine and glasdegib both increase QTc interval. Avoid or Use Alternate Drug. If coadministration unavoidable, monitor for increased risk of QTc interval prolongation.
- granisetron
granisetron and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- histrelin
histrelin increases toxicity of tetrabenazine by QTc interval. Avoid or Use Alternate Drug. Increases risk of torsades de pointes.
- hydroxychloroquine sulfate
hydroxychloroquine sulfate and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- hydroxyzine
hydroxyzine and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- inotuzumab
inotuzumab and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. If unable to avoid concomitant use, obtain ECGs and electrolytes before and after initiation of any drug known to prolong QTc, and periodically monitor as clinically indicated during treatment.
- iobenguane I 131
tetrabenazine will decrease the level or effect of iobenguane I 131 by Other (see comment). Avoid or Use Alternate Drug. Based on the mechanism of action of iobenguane, drugs that reduce catecholamine uptake or that deplete catecholamine stores may interfere with iobenguane uptake into cells, and thus, reduce iobenguane efficacy. Discontinue interfering drugs for at least 5 half-lives before administration of either the dosimetry or an iobenguane dose. Do not administer these drugs until at least 7 days after each iobenguane dose.
- isoflurane
isoflurane and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- lefamulin
lefamulin and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- lithium
lithium and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- mefloquine
mefloquine increases toxicity of tetrabenazine by QTc interval. Avoid or Use Alternate Drug. Mefloquine may enhance the QTc prolonging effect of high risk QTc prolonging agents.
- metoclopramide intranasal
tetrabenazine, metoclopramide intranasal. Either increases effects of the other by Other (see comment). Avoid or Use Alternate Drug. Comment: Avoid use of metoclopramide intranasal or interacting drug, depending on importance of drug to patient.
- mirtazapine
mirtazapine and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- mobocertinib
mobocertinib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. If coadministration unavoidable, reduce mobocertinib dose and monitor QTc interval more frequently.
- olanzapine
olanzapine and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- panobinostat
tetrabenazine and panobinostat both increase QTc interval. Avoid or Use Alternate Drug. Panobinostat is known to significantly prolong QT interval. Panobinostat prescribing information states use with drugs known to prolong QTc is not recommended.
- pimavanserin
pimavanserin and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug. Coadministration may increase the risk of QT prolongation and cardiac arrhythmia.
- pitolisant
tetrabenazine and pitolisant both increase QTc interval. Avoid or Use Alternate Drug.
- ribociclib
ribociclib and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- ropeginterferon alfa 2b
ropeginterferon alfa 2b and tetrabenazine both increase Other (see comment). Avoid or Use Alternate Drug. Narcotics, hypnotics or sedatives can produce additive neuropsychiatric side effects. Avoid use and monitor patients receiving the combination for effects of excessive CNS toxicity.
- safinamide
tetrabenazine decreases effects of safinamide by pharmacodynamic antagonism. Avoid or Use Alternate Drug. Dopamine antagonists may decrease safinamide effects and exacerbate Parkinson disease symptoms.
- sevoflurane
sevoflurane and tetrabenazine both increase QTc interval. Avoid or Use Alternate Drug.
- triptorelin
triptorelin increases toxicity of tetrabenazine by QTc interval. Avoid or Use Alternate Drug. Increases risk of torsades de pointes.
Monitor Closely (56)
- abiraterone
abiraterone increases levels of tetrabenazine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Avoid coadministration of abiraterone with substrates of CYP2D6. If alternative therapy cannot be used, exercise caution and consider a dose reduction of the CYP2D6 substrate.
- albuterol
albuterol and tetrabenazine both increase QTc interval. Use Caution/Monitor.
- alfuzosin
tetrabenazine and alfuzosin both increase QTc interval. Use Caution/Monitor.
- amoxapine
amoxapine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- arformoterol
arformoterol and tetrabenazine both increase QTc interval. Use Caution/Monitor.
- aripiprazole
aripiprazole and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- brexanolone
brexanolone, tetrabenazine. Either increases toxicity of the other by sedation. Use Caution/Monitor.
- cenobamate
cenobamate, tetrabenazine. Either increases effects of the other by sedation. Use Caution/Monitor.
- chlorpromazine
chlorpromazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- ciprofloxacin
ciprofloxacin and tetrabenazine both increase QTc interval. Use Caution/Monitor. Ciprofloxacin elicits minimal effects on QT interval. Caution if used in combination with other drugs known to affect QT interval or in patients with other risk factors.
- clobazam
tetrabenazine, clobazam. Other (see comment). Use Caution/Monitor. Comment: Concomitant administration can increase the potential for CNS effects (e.g., increased sedation or respiratory depression).
- clozapine
clozapine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- daridorexant
tetrabenazine and daridorexant both increase sedation. Modify Therapy/Monitor Closely. Coadministration increases risk of CNS depression, which can lead to additive impairment of psychomotor performance and cause daytime impairment.
- difelikefalin
difelikefalin and tetrabenazine both increase sedation. Use Caution/Monitor.
- droperidol
droperidol and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- esketamine intranasal
esketamine intranasal, tetrabenazine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely.
- fluoxetine
fluoxetine increases effects of tetrabenazine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Decrease tetrabenazine dose by 50% when coadministered with strong CYP2D6 inhibitors.
- fluphenazine
fluphenazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- fostemsavir
tetrabenazine and fostemsavir both increase QTc interval. Use Caution/Monitor. QTc prolongation reported with higher than recommended doses of fostemsavir.
- ganaxolone
tetrabenazine and ganaxolone both increase sedation. Use Caution/Monitor.
- haloperidol
haloperidol and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- iloperidone
iloperidone and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- lasmiditan
lasmiditan, tetrabenazine. Either increases effects of the other by sedation. Use Caution/Monitor. Coadministration of lasmiditan and other CNS depressant drugs, including alcohol have not been evaluated in clinical studies. Lasmiditan may cause sedation, as well as other cognitive and/or neuropsychiatric adverse reactions.
- lemborexant
lemborexant will increase the level or effect of tetrabenazine by sedation. Modify Therapy/Monitor Closely. Dosage adjustment may be necessary if lemborexant is coadministered with other CNS depressants because of potentially additive effects.
- lenvatinib
tetrabenazine and lenvatinib both increase QTc interval. Use Caution/Monitor. Lenvatinib prescribing information recommends monitoring ECG closely when coadministered with QT prolonging drugs.
- lofexidine
tetrabenazine and lofexidine both increase QTc interval. Use Caution/Monitor. ECG monitoring is recommended.
- loxapine
loxapine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- loxapine inhaled
loxapine inhaled and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- lurasidone
lurasidone, tetrabenazine. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Potential for increased CNS depressant effects when used concurrently; monitor for increased adverse effects and toxicity.
- metoclopramide
metoclopramide and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- midazolam intranasal
midazolam intranasal, tetrabenazine. Either increases toxicity of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Concomitant use of barbiturates, alcohol, or other CNS depressants may increase the risk of hypoventilation, airway obstruction, desaturation, or apnea and may contribute to profound and/or prolonged drug effect.
- olanzapine
olanzapine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- osilodrostat
osilodrostat and tetrabenazine both increase QTc interval. Use Caution/Monitor.
- oxaliplatin
oxaliplatin will increase the level or effect of tetrabenazine by Other (see comment). Use Caution/Monitor. Monitor for ECG changes if therapy is initiated in patients with drugs known to prolong QT interval.
- ozanimod
ozanimod and tetrabenazine both increase QTc interval. Modify Therapy/Monitor Closely. The potential additive effects on heart rate, treatment with ozanimod should generally not be initiated in patients who are concurrently treated with QT prolonging drugs with known arrhythmogenic properties.
- paliperidone
paliperidone and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- paroxetine
paroxetine increases effects of tetrabenazine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Decrease tetrabenazine dose by 50% when coadministered with strong CYP2D6 inhibitors.
- perphenazine
perphenazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- pimozide
pimozide and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- prochlorperazine
prochlorperazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- promethazine
promethazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- quetiapine
quetiapine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- quinidine
quinidine increases effects of tetrabenazine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Decrease tetrabenazine dose by 50% when coadministered with strong CYP2D6 inhibitors.
- remimazolam
remimazolam, tetrabenazine. Either increases toxicity of the other by sedation. Modify Therapy/Monitor Closely. Coadministration may result in profound sedation, respiratory depression, coma, and/or death. Continuously monitor vital signs during sedation and recovery period if coadministered. Carefully titrate remimazolam dose if administered with opioid analgesics and/or sedative/hypnotics.
- risperidone
risperidone and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- ritonavir
ritonavir increases effects of tetrabenazine by affecting hepatic enzyme CYP2D6 metabolism. Use Caution/Monitor. Decrease tetrabenazine dose by 50% when coadministered with strong CYP2D6 inhibitors.
- selpercatinib
selpercatinib increases toxicity of tetrabenazine by QTc interval. Use Caution/Monitor.
- sodium sulfate/?magnesium sulfate/potassium chloride
sodium sulfate/?magnesium sulfate/potassium chloride increases toxicity of tetrabenazine by QTc interval. Use Caution/Monitor. Consider predose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias. .
- sodium sulfate/potassium sulfate/magnesium sulfate
sodium sulfate/potassium sulfate/magnesium sulfate increases toxicity of tetrabenazine by QTc interval. Use Caution/Monitor. Consider predose and post-colonoscopy ECGs in patients at increased risk of serious cardiac arrhythmias. .
- stiripentol
stiripentol, tetrabenazine. Either increases effects of the other by sedation. Use Caution/Monitor. Concomitant use stiripentol with other CNS depressants, including alcohol, may increase the risk of sedation and somnolence.
- thioridazine
thioridazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- thiothixene
thiothixene and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- triclabendazole
triclabendazole and tetrabenazine both increase QTc interval. Use Caution/Monitor.
- trifluoperazine
trifluoperazine and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
- voclosporin
voclosporin, tetrabenazine. Either increases effects of the other by QTc interval. Use Caution/Monitor.
- ziprasidone
ziprasidone and tetrabenazine both increase antidopaminergic effects, including extrapyramidal symptoms and neuroleptic malignant syndrome. Modify Therapy/Monitor Closely.
Minor (2)
- azithromycin
azithromycin increases toxicity of tetrabenazine by QTc interval. Minor/Significance Unknown.
- chloroquine
chloroquine increases toxicity of tetrabenazine by QTc interval. Minor/Significance Unknown.
Adverse Effects
>10%
Sedation/somnolence (31%)
Fatigue (22%)
Insomnia (22%)
Depression (19%)
Akathisia (19%)
Extrapyramidal event (15%)
Anxiety (15%)
Nausea (13%)
1-10%
Irritability (9%)
Bruising (6%)
Vomiting (6%)
Decreased appetite (4%)
Dysuria (4%)
Obsessive reaction (4%)
Imbalance (9%)
Parkinsonism/bradykinesia (9%)
Dizziness (4%)
Dysarthria (4%)
Unsteady gait (4%)
Headache (4%)
Frequency Not Defined
QTc prolongation
Neuroleptic malignant syndrome
Orthostatic Hypotension
Restlessness and agitation
Dysphagia
Depression and suicidality
Postmarketing Reports
Nervous system disorders: Tremor
Psychiatric disorders: Confusion, worsening aggression, depression/suicidality
Respiratory, thoracic and mediastinal disorders: Pneumonia
Skin and subcutaneous tissue disorders: Hyperhidrosis, skin rash
Endocrine system: Hyperprolactinemia
Warnings
Black Box Warnings
Increased risk of depression and suicidal thoughts and behavior (suicidality) in patients with Huntington’s disease
Balance risks of depression and suicidality with the clinical need for control of choreiform movements when considering the use of tetrabenazine
Monitor for emergence or worsening of depression, suicidality, or unusual changes in behavior
Inform patients, caregivers and families of the risk of depression and suicidality and instruct to report behaviors of concern promptly to the treating physician
Caution in patients with a history of depression or prior suicide attempts or ideation
Contraindicated in patients who are actively suicidal, and in patients with untreated or inadequately treated depression
Contraindications
Hypersensitivity
Hepatic impairment
Patients who are actively suicidal, or who have untreated or inadequately treated depression (see Black Box Warnings)
Coadministration with deutetrabenazine or valbenazine
Concomitant MAO inhibitor or within 14 days of discontinuing MAO inhibitor
Concomitant use with reserpine
Cautions
Not indicated for treatment of levodopa-induced dyskinetic movements
Should only be used by physicians experienced with treatment of hyperkinetic disorders
Induced postural dizziness reported; however, blood pressure has not been measured during such events;monitoring of vital signs on standing should be considered in patients who are vulnerable to hypotension
Depression and suicidality
- Patients with Huntington’s disease (HD) are at increased risk for depression, suicidal ideation or behaviors (suicidality); this drug increases risk for suicidality in patients with HD
- When considering therapy, the risk of suicidality should be balanced against need for treatment of chorea; all patients should be observed for new or worsening depression or suicidality; if depression or suicidality does not resolve, consider discontinuing treatment
- Patients, their caregivers, and families should be informed of risks of depression, worsening depression, and suicidality associated with therapy, and should be instructed to report behaviors of concern promptly to treating physician; patients with HD who express suicidal ideation should be evaluated immediately
Clinical worsening and adverse effects
- Huntington’s disease is a progressive disorder characterized by changes in mood, cognition, chorea, rigidity, and functional capacity over time; overtime also caused slight worsening in mood, cognition, rigidity, and functional capacity
- Whether these effects persist, resolve, or worsen with continued treatment is unknown; prescribers should periodically reevaluate need for therapy by assessing effect on chorea and possible adverse effects, including depression and suicidality, cognitive decline, parkinsonism, dysphagia, sedation/somnolence, akathisia, restlessness, and disability
- It may be difficult to distinguish between adverse reactions and progression of underlying disease; decreasing the dose or stopping the drug may help the clinician distinguish between the two possibilities; in some patients, underlying chorea itself may improve over time, decreasing the need for therapy
Poor and extensive metabolizers
- Before prescribing a daily dose that is greater than 50 mg per day, patients should be genotyped to determine if they express the drug metabolizing enzyme, CYP2D6; CYP2D6 testing is necessary to determine whether patients are poor metabolizers (PMs), extensive (EMs) or intermediate metabolizers (IMs) of this drug
- Patients who are PMs will have substantially higher levels of the primary drug metabolites (about 3-fold for α-HTBZ and 9-fold for β-HTBZ) than patients who are Ems; the dosage should be adjusted according to patient’s CYP2D6 metabolizer status; in patients who are identified as CYP2D6 PMs, the maximum recommended total daily dose is 50 mg and the maximum recommended single dose is 25 mg
Neuroleptic malignant syndrome (NMS)
- A potentially fatal symptom complex sometimes referred to as neuroleptic malignant syndrome (NMS) has been reported in association with the drug and other drugs that reduce dopaminergic transmission
- Clinical manifestations of NMS are hyperpyrexia, muscle rigidity, altered mental status, and evidence of autonomic instability (irregular pulse or blood pressure, tachycardia, diaphoresis, and cardiac dysrhythmia); additional signs may include elevated creatinine phosphokinase, myoglobinuria, rhabdomyolysis, and acute renal failure
- The diagnosis of NMS can be complicated; other serious medical illnesses (eg, pneumonia, systemic infection), and untreated or inadequately treated extrapyramidal disorders can present with similar signs and symptoms
- Other important considerations in the differential diagnosis include central anticholinergic toxicity, heat stroke, drug fever, and primary central nervous system pathology
- The management of NMS should include immediate discontinuation of the drug, intensive symptomatic treatment and medical monitoring; and treatment of any concomitant serious medical problems for which specific treatments are available
- There is no general agreement about specific pharmacological treatment regimens for NMS; recurrence of NMS has been reported with resumption of drug therapy; if treatment is needed after recovery from NMS, patients should be monitored for signs of recurrence
Parkinsonism
- Therapy may cause parkinsonism; because rigidity can develop as part of underlying disease process in Huntington’s disease, it may be difficult to distinguish between this drug-induced adverse reaction and progression of the underlying disease process
- Drug-induced parkinsonism has the potential to cause more functional disability than untreated chorea for some patients with Huntington’s disease; if a patient develops parkinsonism during treatment, dose reduction should be considered; in some patients, discontinuation of therapy may be necessary
Sedation and somnolence
- Sedation is the most common dose-limiting adverse reaction of this drug; in clinical trials, sedation was the reason upward titration was stopped and/or the dose decreased; in some patients, sedation has occurred at doses lower than recommended doses
- Patients should not perform activities requiring mental alertness to maintain safety of themselves or others, such as operating a motor vehicle or operating hazardous machinery, until they are on a maintenance dose and know how the drug affects them
QTc prolongation
- The drug causes a small increase (about 8 msec) in corrected QT (QTc) interval; QT prolongation can lead to development of torsade de pointes-type ventricular tachycardia with risk increasing as degree of prolongation increases
- Use of this drug should be avoided in combination with other drugs known to prolong QTc, including antipsychotic medications (eg, chlorpromazine, haloperidol, thioridazine, ziprasidone), antibiotics (eg, moxifloxacin), Class 1A (eg, quinidine, procainamide), and Class III (eg, amiodarone, sotalol) antiarrhythmic medications or any other medications known to prolong the QTc interval
- The drug should be avoided in patients with congenital long QT syndrome and in patients with a history of cardiac arrhythmias; certain circumstances may increase risk of occurrence of torsade de pointes and/or sudden death in association with use of drugs that prolong the QTc interval, including bradycardia, hypokalemia or hypomagnesemia, concomitant use of other drugs that prolong the QTc interval, and presence of congenital prolongation of the QT interval
Hyperprolactinemia
- Therapy elevates serum prolactin concentrations in humans; peak plasma prolactin levels have increased after administration of the drug; although amenorrhea, galactorrhea, gynecomastia, and impotence can be caused by elevated serum prolactin concentrations, the clinical significance of elevated serum prolactin concentrations for most patients is unknown
- Chronic increase in serum prolactin levels (although not evaluated) has been associated with low levels of estrogen and increased risk of osteoporosis; if there is a clinical suspicion of symptomatic hyperprolactinemia, appropriate laboratory testing should be done and consideration should be given to discontinuation of therapy
Binding to melanin-containing tissues
- Since the drug or its metabolites bind to melanin-containing tissues, it could accumulate in these tissues over time; this raises the possibility that the drug may cause toxicity in these tissues after extended use; neither ophthalmologic nor microscopic examination of the eye has been conducted in chronic toxicity studies in a pigmented species , such as dogs
- Ophthalmologic monitoring in humans was inadequate to exclude possibility of injury occurring after long-term exposure; the clinical relevance of this drug binding to melanin-containing tissues is unknown
- Although there are no specific recommendations for periodic ophthalmologic monitoring, prescribers should be aware of the possibility of long-term ophthalmologic effects
Drug interaction overview
- Concomitant use of neuroleptics (eg, haloperidol, chlorpromazine, risperidone, olanzapine) may cause additive effects of QTc prolongation, NMS, and extrapyramidal disorders
- Caution with poor CYP2D6 metabolizers or drugs that inhibit CYP2D6 (eg, fluoxetine, paroxetine, quinidine); may markedly increase exposure to tetrabenazine active metabolites (alpha- and beta-HTBZ)
-
Reserpine
- Do not use tetrabenazine and reserpine concomitantly
- Reserpine binds irreversibly to VMAT2 and the duration of its effect is several days
- Caution when switching from reserpine to tetrabenazine; wait for chorea to re-emerge before administering tetrabenazine to avoid overdosage and major CNS depletion of serotonin and norepinephrine
- At least 20 days should elapse after stopping reserpine before starting tetrabenazine
Pregnancy & Lactation
Pregnancy
There are no adequate data on the developmental risk associated with therapy in pregnant women; administration of tetrabenazine to rats throughout pregnancy and lactation resulted in an increase in stillbirths and postnatal offspring mortality
Lactation
There are no data on presence of tetrabenazine or metabolites in human milk, effects on breastfed infant, or on milk production; developmental and health benefits of breastfeeding should be considered along with mother’s clinical need for therapy and potential adverse effects on breastfed infant or underlying maternal condition
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Reversibly inhibits human vesicular monoamine transporter type 2 (VMAT2), resulting in decreased uptake of monoamines (eg, dopamine, serotonin, norepinephrine, histamine) into synaptic vesicles and depletion of monoamine stores from nerve terminals
This effect is similar to reserpine, but with less peripheral activity and is shorter-acting
Absorption
Extent of absorption is at least 75%
Distribution
Protein Bound: 82-85%; 59-68% (metabolites)
Parent drug and metabolites bind to melanin-containing tissues (ie, eye, skin)
Rapidly distributed in brain (highest binding in striatum, lowest binding in cortex)
Metabolism
Rapid and extensively metabolized in liver by carbonyl reductase to active metabolites
Metabolites (active): alpha-hydroxytetrabenazine, beta-hydroxytetrabenazine
Active metabolites are predominantly metabolized by CYP2D6
Elimination
Half-Life: 7 hr (alpha-hydroxytetrabenazine); 5 hr (beta-hydroxytetrabenazine)
Excretion: 75% urine; 7-16% feces; excreted mostly as metabolites
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| Xenazine oral - | 25 mg tablet |  | |
| Xenazine oral - | 12.5 mg tablet |  | |
| tetrabenazine oral - | 12.5 mg tablet |  | |
| tetrabenazine oral - | 25 mg tablet |  | |
| tetrabenazine oral - | 25 mg tablet |  | |
| tetrabenazine oral - | 25 mg tablet |  | |
| tetrabenazine oral - | 25 mg tablet | | |
| tetrabenazine oral - | 12.5 mg tablet |  | |
| tetrabenazine oral - | 25 mg tablet |  | |
| tetrabenazine oral - | 12.5 mg tablet |  | |
| tetrabenazine oral - | 12.5 mg tablet |  | |
| tetrabenazine oral - | 25 mg tablet |  | |
| tetrabenazine oral - | 12.5 mg tablet |  | |
| tetrabenazine oral - | 12.5 mg tablet | | |
| tetrabenazine oral - | 25 mg tablet |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
tetrabenazine oral
TETRABENAZINE - ORAL
(TE-tra-BEN-a-zeen)
COMMON BRAND NAME(S): Xenazine
WARNING: Tetrabenazine can sometimes increase the risk of depression and suicidal thoughts/attempts. People with Huntington's disease are more likely to have depression and suicidal thoughts/attempts. Discuss the risks and benefits of this medication with your doctor. People who are not being treated for their depression and suicidal thoughts/attempts, or people who have ongoing symptoms of these conditions (even with medication/treatment) must not use tetrabenazine. Tell your doctor right away if you or your family/caregivers notice that you have new/worsening symptoms of depression, sadness, loss of interest in activities you used to enjoy, suicidal thoughts/attempts, or other mental/mood/behavior changes (such as new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, strong/abnormal urges, severe restlessness, very rapid speech).
USES: Tetrabenazine is used to decrease the uncontrollable movements (chorea) caused by Huntington's disease. However, it is not a cure for the disease. Reducing the chorea will help you take part in more of your normal daily activities. This medication is thought to work by decreasing the amount of certain natural substances in the brain (monoamines such as dopamine, serotonin, and norepinephrine), which are involved with nerve and muscle function. Tetrabenazine belongs to a class of drugs called monoamine depletors.
HOW TO USE: Read the Medication Guide provided by your pharmacist before you start using tetrabenazine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.Take this medication by mouth with or without food, usually once a day in the morning when you first start treatment or as directed by your doctor. Your doctor may gradually increase your dose to 2 or 3 times a day over several weeks. A slow increase in your dose will help your doctor find the best dose for you while keeping side effects as low as possible.The dosage is based on your medical condition, response to treatment, and other medications you may be taking. Be sure to tell your doctor and pharmacist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Take this medication regularly to get the most benefit from it. To help you remember, take it at the same time(s) each day.If you stop taking this drug for several days, then start taking it again, you may need to slowly increase your dose until you reach the regular dose you had been taking. Follow your doctor's directions on how to restart treatment.Tell your doctor if your uncontrolled movements do not improve or if they worsen.
SIDE EFFECTS: See also Warning section.Drowsiness, trouble sleeping, tiredness, dizziness, nausea, and vomiting may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly. Your doctor may need to adjust your dose to reduce these side effects.To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Sometimes tetrabenazine can cause side effects that are similar to the symptoms of worsening Huntington's disease. Your doctor may need to adjust your dose to see if these side effects are due to the drug or to the disease. Tell your doctor right away if any of these serious side effects occur: mental/mood changes (such as new/worsening depression, suicidal thoughts/attempts, problems with thinking), Parkinson's disease symptoms (such as shaking/tremors, slowed movement, loss of balance), trouble swallowing, restlessness.Tell your doctor right away if any of these unlikely but serious side effects occur: signs of increased prolactin hormone (such as enlarged breasts, abnormal breast milk production, decreased sexual ability, a change in menstrual cycle).This medication may rarely cause a very serious condition called neuroleptic malignant syndrome (NMS). Get medical help right away if you have any of the following symptoms: fever, muscle stiffness/pain/tenderness/weakness, severe tiredness, severe confusion, sweating, fast/irregular heartbeat, dark urine, signs of kidney problems (such as change in the amount of urine).A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: See also Warning section.Before taking tetrabenazine, tell your doctor or pharmacist if you are allergic to it; or to deutetrabenazine; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: breast cancer, liver problems, certain heart problems (fast/slow/irregular heartbeat, QT prolongation in the EKG).This drug may make you dizzy or drowsy. Alcohol or marijuana (cannabis) can make you more dizzy or drowsy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Limit alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.It is not known whether this drug passes into breast milk. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug are: valbenazine.Taking MAO inhibitors with this medication may cause a serious (possibly fatal) drug interaction. Do not take any MAO inhibitors (isocarboxazid, linezolid, metaxalone, methylene blue, moclobemide, phenelzine, procarbazine, rasagiline, safinamide, selegiline, tranylcypromine) during treatment with this medication. Most MAO inhibitors should also not be taken for two weeks before and after treatment with this medication. Ask your doctor when to start or stop taking this medication.Tetrabenazine is very similar to deutetrabenazine. Do not use medications containing deutetrabenazine while using tetrabenazine.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: muscle stiffness/pain, fixed upward position of the eyeballs, sweating, dizziness, severe drowsiness.
NOTES: Do not share this medication with others.Laboratory and/or medical tests may be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.
MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose. Take your next dose at the regular time. Do not double the dose to catch up.
STORAGE: Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.
Information last revised February 2022. Copyright(c) 2022 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
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Adding plans allows you to:
- View the formulary and any restrictions for each plan.
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