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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.
Perhaps one of the best common-sense statements I have read about treatment appeared in a review article by Srour et al. (2008). They write:
The first therapeutic approach in tic disorders
is education and demystification of symptoms.
Persons in frequent contact with the
child should be informed about tics, fluctuations
and possible co-morbidities. It is important
to emphasize the uselessness of constantly
asking the child to control his/her tics.
Such requests create tension which often exacerbates
symptoms. The goal is to improve the
tolerance of symptoms, and avoid situations
that will augment stress or embarrassment.
Following a complete evaluation, the treatment
of tics and comorbidities should be prioritized
according to the impairment caused by each
problem. Physicians considering pharmacological
treatments should be aware of the fluctuating
nature of tics and the effect of comorbidities
on outcome. |
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Medications
for Tics
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Block (2008), Srour et al. (2008), and Shprecher and Kurlan (2009) provide discussions and reviews of current treatment approaches; the latter two articles are available online in free, full-text version.
In terms of effectiveness, neuroleptic medications that block dopamine have generally been the most effective tic medications. 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®).
Not all neuroleptics have been adequately studied using controlled designs to determine their effect on tics. For example, a recent open label study by
McCracken et al. (2008) investigated the use of olanzapine (Zyprexa®) in treating children and adolescents with tics. They reported significant benefit in tics as well as in associated symptoms, but the absence of adequate control groups precludes any firm conclusions.
Aripiprazole (Abilify®) is an atypical neuroleptic that has also been explored for its possible efficacy in treating tics. A number of preliminary reports suggest that it may be effective, including in patients who did not obtain satisfactory benefit from other neuroleptic medications [cf, Davies et al. (2006);
Kawohl et al. (2008)]. Seo, Sung, et al. (2008) conduced an open label study in a small sample of children and teens and reported significant decreases in the scores of motor and phonic tics, global impairment, and global severity that appeared by the third week of treatment. An open label study, however, does not meet the "gold standard" for pharmaceutical research. Similarly, Budman et al. (2008) conducted a
retrospective review of 37 children and teens with (8 had TS-only; the remaining 29 had TS+). Their review indicated that tics improved and explosive outbursts improved in those who did not discontinue treatment. They, too, concluded that aripiprazole warrants further investigation as a treatment for TS.
Tetrabenazine (Xenazine® Nitoman® in Canada) is another medication that affects the dopamine system, but unlike medications that block dopamine, Tetrabenazine depletes presynaptic dopamine and serotonin stores and blocks postsynaptic dopamine receptors. Although several studies and reviews have suggested that tetrabenazine may be of benefit in treating TS [cf, Ondo et al. (2008); Porta, Sassi et al. (2008)], it has not produced the kind of controlled research necessary to obtain FDA approval.
At the present time, the only medications approved for treating tics are haloperidol (Haldol®) and pimozide (Orap®).
In the U. S., clonidine hydrochloride (Catapres®), an alpha 2-adrenergic agonist, is often prescribed for tics, even though it is not as effective as the neuroleptics. Clonidine is actually a blood pressure
medication, and does not pose the same risks as the neuroleptic medications. It also may have some beneficial effects on the symptoms of Attention Deficit Hyperactivity Disorder, which is frequently comorbid with TS. Du, Li et al (2008) recently compared the clonidine patch to placebo in children and teens. After 4 weeks of treatment, there was a signficant improvement in the children's Tourette's symptoms compared to the control group.
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. Another disadvantage of clonidine is that it may take two to three months before an effect is detected, whereas neuroleptics often provide symptom relief within days of starting treatment.
Clonazepam (Klonopin®) has also been used with some success in augmenting other medications, although its may benefit be in reducing anxiety and thereby reducing tics by reducing anxiety. Its most common side effects are sedation and unsteadiness.
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Adverse
Effects of Medications
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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.
Although the newer generation of neuroleptic medications is somewhat less likely to cause significant weight gain, they are associated with metabolic syndrome, which can lead to insulin resistance, high blood pressure (hypertension), and high levels of triglycerides. Individuals with metabolic syndrome
are at a two to three-fold increased risk of cardiovascular
mortality and a two-fold increased
risk of all-cause mortality (Lakka et al, 2002). In 2003, the
US FDA asked the manufacturers of all atypical
neuroleptics to revise 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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Nicotine
Patch
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Some clinicians and
investigators explored the value of
nicotine patches or mecamylamine (Inversine®),
a medication that blocks nicotine receptors in the
brain. Over all, however, it seems that the
nicotine patch's promise is as a supplement to tic
medication, and not as a sole treatment. A study by Howson et al. (2004) found that a single nicotine patch was effective in reducing complex tics and improving attention in children and teens receiving neuroleptic medication when compared to children on neuroleptics given a placebo.
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Information
Section: Conditions
Condition:
Tourette's
Syndrome
Article: Treatment of Tics
and Tourette's Syndrome
Source: Leslie E. Packer,
PhD
This File Last Updated:
February 2009
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Article
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Tourette
Syndrome "Plus" © Copyright 1998 - 2009 Leslie
E. Packer, PhD. except as noted.
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This page last updated February 8, 2009.
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