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When a child or adult
is diagnosed with TS, often the first question
asked is "Is there a cure?" After finding out that
there is no cure, the next question is usually,
"What medication should we use?"
The diagnosis of TS
does not mean that the person necessarily needs
medication. Sometimes just educating the patient
and those around him/her can make a significant
difference, as can accommodations or modifications
in school or on the job.
If the child is not
suffering from the tics, and the child is
functioning well in the significant areas of
his/her life (home, school, peers), then stop, take
a deep breath, and consider giving everyone time to
learn about TS, finding out what can be
accomplished by environmental modifications, and
helping the child simply accept that they have TS.
If you or your child
has Tourette's plus comorbid or associated
conditions, then you will also need to prioritize
to determine what to treat for: is it the tics that
are really the most significant problem, or is it
any ADHD or OCD or mood disorder? The medications
you would use for tics are not necessarily what you
would use for another condition and treating one
condition might make symptoms of another condition
worse. You will also want to learn about
research-validated alternatives to medication.
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In the U. S., the
most frequently prescribed medications are
clonidine hydrochloride (Catapres®) and
guanfacine (Tenex®), two alpha 2-adrenergic
agonists. Clonidine is actually a blood pressure
medication that was found to ameliorate tics.
Clonidine and guanfacine can generally be taken by
individuals who have normal blood pressure.
Clonidine is available in tablet and
sustained-release (transdermal) patch form. At the
present time, guanfacine is not available in patch
form.
Like all medications,
clonidine does have some side effects that can be
problematic. The most problematic side effects
reported have been dry mouth and drowsiness or
somnolence. Guanfacine has the same side effect
profile, although the drowsiness tends to be
somewhat less. Although many patients adjust to the
medication's side effects, others don't and
discontinue the medication. Even if clonidine does
work, it may take time before its effect builds up
in the system.
Because many children
and adults with TS also have ADHD, it should be
noted that both medications are also used in the
treatment of ADHD.
While clonidine and
guanfacine may be the first line of tic treatment
for may clinicians, they are not necessarily the
most effective, so if they don't work, don't become
disheartened. Their use as a first-line treatment
is more related to their side effect profile and
their potential benefit in ameliorating ADHD than
to their effectiveness in treating tics. For
decades, there has been some concern that using
stimulant medications to treat ADHD might induce or
worsen tics in some patients. Recent studies
suggest that stimulants can be safely prescribed to
children and adults who have both tics and ADHD,
although a combination of clonidine and
methylphenidate (Ritalin) appears to be more
effective than either medication alone. When
individual medications were compared, clonidine was
superior to Ritalin in reducing impulsivity and
hyperactivity, while Ritalin was superior in
reducing inattention. The combined treatment was
also the most effective treatment in reducing the
severity of a child's tics, with 75% of the
children showing improvement.
Neuroleptic
medications are often used in the treatment of
psychosis, but they are also often used (in small
doses) to help reduce tics. This does not mean that
an individual with tics is psychotic any more than
being on clonidine for tics would mean that the
person had a blood pressure problem: in both
situations, we are talking about using medications
approved for one purpose being used for another
purpose (tics).
The class of
medications known as 'neuroleptics' include older
neuroleptics such as pimozide (Orap®),
haloperidol (Haldol®), fluphenazine
(Prolixin®), and sulpiride (not legal for use
in the U.S.), and the newer "atypical" neuroleptics
such as risperidone (Risperdal®), olanzapine
(Zyprexa®), thiothixene (Navane®),
clozapine (Clozaril®), quetiapine
(Seroquel®), ziprasidone (Geodon®), and
aripiprazole (Abilify®).
Based on available
research, risperidone appears to be an effective
treatment for tics when compared to placebo, is at
least as effective as clonidine in the treatment of
tics, and may be of some value in treating
associated behavioral symptoms in some conditions.
Its effect on obsessive-compulsive behavior,
however, is not well understood. Although some
studies have found that risperidone can be an
effective augmenting agent in the treatment of
treatment-resistant OCD, other reports have
described sudden and acute onset or exacerbation of
obsessive-compulsive symptoms in children and
adults being treated with risperidone.
In addition to being
more effective for many patients, one of the other
advantages of the neuroleptics compared to
clonidine is that the neuroleptics tend to work
faster -- if they are going to help, you will
generally know within a matter of days or a few
weeks, even if you are building up slowly on the
dose. Neuroleptics should generally not be
discontinued abruptly, however, as you might get
some withdrawal-emergent effects that look like
tics or involuntary movements.
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Although the
neuroleptics may be more potent in treating tics
than clonidine, they have a more severe side effect
profile. Of particular concern are what are called
"extrapyramidal syndromes" which include the risk
of tardive dyskinesia (TD) and neuroleptic
malignant syndrome (NMS). TD is a generally (but
not always) irreversible movement disorder that may
develop in some small percentage of patients who
are on neuroleptics, while NMS is a rare but
life-threatening reaction characterized by high
fever, rigidity, mental changes, and instability of
the autonomic system. NMS is usually treatable and
reversible.
The actual number of
cases in which TD has developed in patients with TS
is extremely small (perhaps because of the low
doses used when treating tics), but fear of
developing TD has led many parents and patients to
avoid those medications. Tarsy et al. (2002)
provide a review of the research on the
extrapyramidal side effects of the newer
neuroleptic medications.
Concerns have also
been raised about cardiac changes (in the QT
interval) with pimozide and ziprasidone, and many
physicians will recommend pre-medication monitoring
and periodic monitoring throughout
treatment.
In 2003, the
US FDA asked the manufacturers of all atypical
neuroleptics to rev ise their warning labels.
Warnings now include the increased risk of diabetes
mellitus and hyperglycemia.
In terms of
day-to-day adverse effects, sleepiness, depressed
mood, and weight gain are the most frequent
concerns with the neuroleptics.
As with most
medications, potential interaction between
neuroleptics and other medications requires careful
patient education.
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