Tourette's%20syndrome%20-and-%20other%20tic%20disorders Treatment

• May be considered if symptoms interfere with normal functioning
• Successful treatment of comorbid disorder usually decreases tic severity
• There is no cure for Tourette syndrome (TS); aim of pharmacological therapy is to reduce the frequency and severity of tics
• Goals should be to relieve tic-related discomfort/embarrassment and to allow the patient to function as normally as possible
• Choice of treatment depends on the following factors: severity of symptoms, address the most problematic symptom(s), patient’s sense of urgency for treatment, and patient’s aversion to risk of likely or unlikely adverse effects

Alpha-Adrenergic Agents

Clonidine

• May be preferred over antipsychotic medications because of decreased risk of acute and long-term side effects
• Useful for children who are hyperactive, impulsive and disinhibited
• Has been shown to improve tics and attention-deficit/hyperactivity disorder (ADHD) 

Guanfacine

• Found to be less sedating and less hypotensive than Clonidine
• Has been shown to improve tics and attention-deficit/hyperactivity disorder
• Ensures more patient compliance as it can be given once at bedtime or 2x daily as compared with 3-4x daily doses of Clonidine

Neuroleptics

• Neuroleptics are considered the most effective drugs

Conventional/Typical Antipsychotics

• Haloperidol
  • Side effects tend to limit use and there are other agents that may be better tolerated
  • Many case reports and placebo-controlled studies have shown effectiveness

• Pimozide
  • Shown to be effective in Tourette syndrome (TS)
  • May be more effective than Haloperidol but studies comparing the 2 agents have been conflicting

Selective Dopamine D₂ Receptor Antagonists

• Sulpiride
  • A small number of uncontrolled studies have shown Sulpiride to be effective in treating tics in 59% of patients
  • Improves aggressive obsessive-compulsive behavior and mood

• Tiapride
  • Small number of studies have shown that it reduces tics without affecting cognitive impairment

• Tetrabenazine
  • Depletes dopamine by inhibiting vesicular monoamine transporter type 2
  • As effective as the typical neuroleptics but does not cause tardive dyskinesia
  • Studies have shown to be effective in hyperkinetic movement disorders

Atypical Antipsychotic

• Aripiprazole 
  • Indicated for treatment of Tourette’s disorder in pediatric patients 6-18 years
  • Acts as antagonist at D2 receptors under hyperdopaminergic conditions and displays agonist properties under hypodopaminergic conditions
• Risperidone
  • Extrapyramidal syndrome side effects are usually less compared with conventional antipsychotics
  • Most extensively studied of the atypical antipsychotics in the treatment of Tourette syndrome
  • Several studies show Risperidone is effective for Tourette syndrome
  • Has been advocated as 1st-line agent in patients with tics & obsessive-compulsive disorder symptoms
  • Based on a retrospective chart review, it has been shown to decrease aggressive behavior in patients with Tourette syndrome

Selective Serotonin Re-uptake Inhibitors (SSRIs)¹

• Considered 1st-line agents in patients with significant depression or obsessive-compulsive disorder symptoms
• May improve tics in some patients, may worsen them, or may have no effect on tics in others
• Eg Fluoxetine

Selective Noradrenaline Reuptake Inhibitor (SNRI)

• Atomoxetine
  • A nonstimulant found to be modestly effective in the treatment of Tourette syndrome-related attention-deficit/hyperactivity disorder (ADHD)

Tricyclic Antidepressant¹

• Clomipramine
  • Has nonselective reuptake blocking properties that relieve symptoms of obsessive-compulsive disorder (OCD) 

Stimulants²

• Considered 1st-line agents in patients with attention-deficit/hyperactivity disorder
• Methylphenidate may be better tolerated than Dextroamphetamine in patients with Tourette Syndrome
• Methylphenidate and Clonidine have additive benefits in Tourette syndrome and attention-deficit/hyperactivity disorder

Botulinum Toxin

• Involves local intramuscular (IM) injection of the toxin to the affected muscle site
• Most useful for persistent, focal motor (eg eye blinking, neck and shoulder tics), and sometimes vocal tics by temporarily weakening the affected muscles
• Tic and tic urges have been shown to improve
• Effects can be seen in the absence of gross weakness
• Lasts for only 12-16 weeks

Other Agents Reported to Improve Tics

• Topiramate
  • Alternative agent in patients with mild but troublesome tics who are intolerant or unresponsive to other treatment agents
  • More studies are needed to confirm safety and efficacy
• Baclofen, Clonazepam, Fluphenazine, Levetiracetam, Lithium, Naloxone, Nicotine, Olanzapine, Quetiapine, Talipexole, Ziprasidone

¹Please refer to Obsessive-Compulsive Disorder Management Chart for detailed discussion on treatment.

²Please refer to Attention Deficit/Hyperactivity Disorder Management Chart for detailed discussion on treatment

Behavioral Treatment

• Individualized, specifically based on the needs of the patient
• May be a treatment option for patients who prefer non-pharmacological treatment or patients intolerant or unresponsive to pharmacological therapy
• Most disabling symptoms should be targeted first
• Interventions which have been used in the treatment of tics:
  • Cognitive therapy 
    • Recommended as 1st-line treatment for patients with tic disorders and obsessive-compulsive disorder (OCD)
  • Habit-reversal training consists of tic-awareness training and competing-response training
    • May be effective in improving tics and controlling symptoms in Tourette syndrome (TS) based on findings from unblinded trials and a controlled trial with blinded outcome assessment
  • Massed negative practice
  • Assertiveness training
  • Relaxation therapy
  • Awareness training (including self-monitoring)
• Comprehensive Behavioral Intervention for Tics (CBIT) composed of habit reversal training, relaxation training and functional interventions addressing situations which sustain or worsen tics is a recommended treatment option for patients with tics

Deep Brain Stimulation

• An invasive neurosurgical procedure reserved for severe refractory cases of Tourette syndrome
• Considered to be an experimental option for intractable cases
• The largest published trial showed a mean reduction of 29% in the YGTSS

Exposure & Response Prevention

• Patients who have in a prolonged period of time with unpleasant premonitory sensations (exposure) and resisting the tic (response prevention), the patients may learn to tolerate the unpleasant sensation (habituation)
  • Habituation will lessen the urge or need to give into the tic, resulting in the reduction of tic behavior