An update on the pharmacological management of Tourette syndrome and emerging treatment paradigms

ABSTRACT

Introduction

Tourette syndrome (TS) is a childhood-onset neurobehavioral disorder characterized by tics. Pharmacotherapy is advised for patients whose symptoms affect their quality of life.

Areas covered

The authors review the tic phenomenology and TS diagnostic criteria. The bulk of this article focuses on pharmacotherapeutic options for treating tics. They also highlight pharmacotherapies in the research pipeline.

Expert opinion

Tic treatment must be tailored to individual needs. Behavioral therapy is the first line of treatment. Most with bothersome tics need pharmacotherapy and rarely, for medication-refractory cases, surgical therapy is indicated. Alpha-2 agonists are considered in patients with mild tics, especially in those with attention deficit with or without hyperactivity. Second-generation antipsychotics like aripiprazole and tiapride may be considered for severe tics. However, prescribers should be mindful of potential side effects, especially drug-induced movement disorders. Botulinum toxin injections may be considered for focal motor tics. Topiramate can be considered when other treatments are ineffective, and its benefits outweigh the risks. The same holds true for vesicular monoamine transporter-2 inhibitors, as they are deemed to be safe and effective in real-world use and open-label trials despite not meeting primary endpoints in placebo-controlled trials. Cannabinoids may be considered in adults if the approaches above do not control tics.

KEYWORDS:

• Tourette syndrome
• tics
• alpha-2 agonists
• aripiprazole
• VMAT2
• Botulinum toxin

Article highlights

• Behavioral therapy should be considered as the first-line treatment option for the management of tics in Tourette syndrome.

• Pharmacotherapy may be needed when tics impair social interactions, academic and work performance and otherwise affect the quality of life.

• Alpha-agonists, such as guanfacine, may be considered in patients with mild tics, especially in those with attention-deficit/hyperactivity and impulse control disorder.

• Dopamine receptor-blockers, such as aripiprazole, are highly potent in ameliorating tics, but carry the risk of drug-induced movement disorder, including tardive dyskinesia and metabolic syndrome.

• Although not backed by placebo-controlled randomized trials, given their efficacy in ameliorating tics and relative safety (e.g. no risk of tardive dyskinesia) in long-term real-world experience, vesicular monoamine transporter-2 inhibitors may be considered as a treatment option.

Declaration of interest

A Lenka serves Frontiers in Neurology and Annals of Movement Disorders journals as an associate editor. J Jankovic’s institution has received research or training grants from Abbott Medical Device, AbbVie, Amneal, Boston Scientific, Medtronic, Merz, the Michael J Fox Foundation for Parkinson’s Research and the Parkinson’s Foundation. He has also served as a consultant for AEON BioPharma; AbbVie and Revance Therapeutics. Furthermore, he has received royalties from Cambridge; Elsevier; Medlink: Neurology; Lippincott Williams and Wilkins; UpToDate; Wiley-Blackwell and has served on the following editorial boards: Expert Review of Neurotherapeutics; Medlink; Neurology in Clinical Practice; Therapeutic Advances in Neurological Disorders; Neurotherapeutics; Toxins; Tremor and Other Hyperkinetic Movements and the Journal of Parkinson’s Disease.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.