Current pharmacotherapy for tic disorders

ABSTRACT

Introduction

Though many unanswered questions about the pathophysiology of Tourette Syndrome remain, several pharmacotherapies for tics have been studied, with varying results in terms of efficacy and the strength of evidence.

Areas covered

This literature review encompasses pharmacotherapies for tics. The pharmacotherapies discussed in this review include: alpha agonists, antipsychotics, topiramate, botulinum toxin, and dopamine depleters.

Expert opinion

Once the presence of tics is confirmed and psychoeducation and support are provided to patients and caregivers, one must examine the degree of tic-related impairment and the presence of psychiatric comorbidities. These factors influence treatment decisions as the presence of comorbidity and related impairment may shift the treatment target. When selecting a medication for tics, the presence of ADHD (the most frequent comorbidity) strengthens the case for choosing an alpha agonist. The case for antipsychotic medications is strongest when tic-related impairment is severe and/or the tics are refractory to more conservative measures. All medications require drug safety monitoring procedures and reevaluation over time.

KEYWORDS:

• Tourette syndrome
• pharmacotherapy
• antipsychotic medications
• alpha adrenergic agonist medications

Article highlights

• Alpha agonists are considered first-line pharmacotherapy for tics in the setting of Tourette syndrome (TS) and have received special attention in the treatment of tics in cases of TS comorbid with attention deficit hyperactivity disorder (ADHD).

• When selecting pharmacotherapy for tics, presence of comorbid ADHD strengthens case for alpha agonists.

• Antipsychotics are considered most effective and potent pharmacotherapy for tics but use is limited by side effects - sedation, metabolic side effects and drug-induced movement disorders - we consider aripiprazole the first choice among antipsychotics.

• Pharmacotherapy for tics may be selected when benefits are seen to outweigh risks, taking into account whether or not tics cause impairment, interfere with daily life, or cause emotional distress or physical injury.

• Clinical observation and psychoeducation may be sufficient in milder cases.

• Strong evidentiary support for comprehensive behavioural interventions for tics (CBIT) including habit reversal therapy (HRT) make this first-line for older children, though CBIT/HRT availability may be limited.

This box summarizes key points contained in the article.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer Disclosures

One referee declares that they are currently involved in the study of long term TEV-50717 for the treatment of children and adolescents with Tourette’s Syndrome. One referee also declares that they’ve received research support from a start-up company that works on cannabis-related research as well as well as having worked as a clinical investigator for two VMAT2 inhibitor trials. Their institution also has a financial conflict associated with an alpha-2-agonist patent (guanfacine). Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Additional information

Funding

This manuscript was not funded.