Tic Disorders

Tics, common in Tourette syndrome (TS), are managed with education, behavioral therapy (HRT), and medications like VMAT2 inhibitors, antipsychotics, alpha adrenergic agents, or topiramate. Severe cases may benefit from deep brain stimulation (DBS). Comorbid conditions like ADHD and OCD may require SSRIs, alpha adrenergic agonists, or CNS stimulants.

2024-01-06 21:07:46 - Editor

Tics Overview:

Tics are sudden and brief intermittent movements. Tics could be either motor, such as, eye blinking, shoulder shrugging and facial grimacing or phonic, such as, grunting, throat clearing or moaning. Transient tics usually last less than one year. However, the majority of tics last longer and are features of Tourette syndrome (TS). The hallmark of Tourette syndrome is the occurrence of multiple motor and phonic tics. Most patients with TS also have associated comorbidities, such as, attention deficit hyperactivity disorder (ADHD) and/or obsessive compulsive disorder (OCD). (1, 2)

Management of Tourette Syndrome:

The management of TS includes both non-pharmacological and pharmacological approach. Education and counselling about the natural history of TS and its comorbidities are very important for patients, families, teachers and employers. Behavioural therapy like habit reversal training (HRT) is also important. (2, 3)

Pharmacological Therapy for TS:

Pharmacological therapy goal is to reduce the frequency of tics in order to improve the function and quality of life. However, there is no cure for TS. Patients with mild and non- disabling tics may not require active therapy. Pharmacological treatment is reserved to those with tics which cause psychosocial, physical and/or functional problems which affect patient's daily activities and quality of life. For patients with TS who have only phonic tics, treatment with botulinum toxin injections into the affected muscles may be effective. Otherwise, medical treatment includes antidopaminergic drugs such as vesicular monoamine transporter type 2 (VMAT2) inhibitors, antipsychotic agents, alpha adrenergic agents or topiramate. (4, 5) Pharmacological therapy goal is to reduce the frequency of tics in order to improve the function and quality of life. However, there is no cure for TS. Patients with mild and non- disabling tics may not require active therapy. Pharmacological treatment is reserved to those with tics which cause psychosocial, physical and/or functional problems which affect patient's daily activities and quality of life. For patients with TS who have only phonic tics, treatment with botulinum toxin injections into the affected muscles may be effective. Otherwise, medical treatment includes antidopaminergic drugs such as vesicular monoamine transporter type 2 (VMAT2) inhibitors, antipsychotic agents, alpha adrenergic agents or topiramate. (4, 5)

VMAT2 Inhibitors for TS:

VMAT2 inhibitors include tetrabenazine at a starting dose of 6.25 mg twice daily with a gradual escalation, up to a maximum of 75 mg daily, depending on the age of the patient, response, and side effects. Deutetrabenazine at a starting dose of 6 mg daily is an alternative option. (5, 6)

Antipsychotic Agents in TS:

Antipsychotic agents for TS include first generation agents, such as, fluphenazine (1mg daily). Second generation antipsychotic agents include risperidone (0.25- 0.5 mg per day), haloperidol (1- 2 mg/day) and aripiprazole (2-5 mg once daily). (7, 8, 9)

Alpha Adrenergic Agonists for TS:

Alpha adrenergic agonists, such as, guanfacine (0.5 mg daily) and clonidine (0.05 mg twice daily) may be helpful in patients with predominant behavioural problems including impulse control and rage attacks. (10, 11)

Topiramate in TS:

Topiramate as an anticonvulsant, at a dose of 25 mg daily may provide short term benefit for tic suppression in patients with TS. (12)

Deep Brain Stimulation in TS:

Patients with TS who have disabling tics which are refractory to medical treatment may be candidates for deep brain stimulation (DBS) of globus pallidus or thalamus. (13)

Comorbid OCD in TS:

Comorbidities include obsessive compulsive disorder (OCD) which may benefit from cognitive behavioural therapy and a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine at 20 mg daily. Patients who do not respond to these measures could benefit from second generation antipsychotic drugs, such as, risperidone at 0.25 mg/day. DBS is an investigational treatment for refractory OCD. (14, 15, 16)

Comorbid ADHD in TS:

Also, attention deficit hyperactivity disorder (ADHD) may respond to alpha adrenergic agonists including guanfacine (0.5mg once daily) and clonidine (0.05 mg at bedtime). Also, CNS stimulants, such as methylphenidate (10 - 20mg/day in 2 divided doses) may be considered. (17)

References

More Posts