Canadian Guidelines for the Evidence-Based Treatment of Tic Disorders: Pharmacotherapy

Abstract

This article seeks to provide the practising clinician with guidance on the pharmacological management of tic disorders in children and adults. We performed a systematic review of the literature on the treatment of tic disorders. A multi-institutional group of 14 experts in psychiatry, child psychiatry, neurology, pediatrics, and psychology engaged in a consensus meeting. The evidence was presented and discussed, and nominal group techniques were employed to arrive at consensus on recommendations. A strong recommendation is made when the benefits of treatment clearly outweigh the risks and burdens, and can apply to most patients in most circumstances without reservation. With a weak recommendation, the benefits, risks, and burdens are more closely balanced, and the best action may differ depending on the circumstances. Based on these principles, weak recommendations were made for the use of pimozide, haloperidol, fluphenazine, metoclopramide (children only), risperidone, aripiprazole, olanzapine, quetiapine, ziprasidone, topiramate, baclofen (children only), botulinum toxin injections, tetrabenazine, and cannabinoids (adults only). Strong recommendations were made for the use of clonidine and guanfacine (children only). While the evidence supports the efficacy of many of the antipsychotics for the treatment of tics, the high rates of side effects associated with these medications resulted in only weak recommendations for these drugs. In situations where tics are not severe or disabling, the use of a medication with only a weak recommendation is not warranted. However, when tics are more distressing and interfering, the need for tic suppression to improve quality of life is stronger, and patients and clinicians may be more willing to accept the risks of pharmacotherapy.

Clinical Motor and Cognitive Neurobehavioral Relationships in the Basal Ganglia

“…Tics are suppressed reliably by dopamine antagonists and OCD is improved by selective serotonin-reuptake inhibitors (SSRIs) [81]. These facts implicate the dopaminergic and serotonergic pathways and suggest the candidate loci for TS abnormalities.…”

Commentary: Are alpha‐2 agonist really effective in children with tics with comorbid ADHD? A commentary on Whittington et al. (2016)

“…This systematic review importantly extends on the results of previous meta-analyses in this area which combined pediatric and adult trial by demonstrating similar treatment effects when trials are restricted to pediatric populations (Weisman, Qureshi, Leckman, Scahill, & Bloch, 2013). Given that roughly one half to two thirds of children with TS have an improvement in tic symptoms that coincides with adolescents, it is hypothesized that adults with continued TS may represent a distinct subgroup of all individuals with TS and it remains unclear how generalizable neuroimaging, genetic, and treatment studies conducted in adults is to the larger population affected by tic symptoms as children.The current guidelines on treating children with TS are supported by the evidence presented in this and other systematic reviews (Murphy, Lewin, Storch, & Stock, 2013;Pringsheim et al, 2012;Roessner et al, 2011). Specific guidelines for the treatment of tic disorders in children suggest the use of antipsychotic medications and alpha-2 agonists for the treatment of tics (Murphy et al, 2013;Pringsheim et al, 2012;Roessner et al, 2011).…”

“…The current guidelines on treating children with TS are supported by the evidence presented in this and other systematic reviews (Murphy, Lewin, Storch, & Stock, 2013;Pringsheim et al, 2012;Roessner et al, 2011). Specific guidelines for the treatment of tic disorders in children suggest the use of antipsychotic medications and alpha-2 agonists for the treatment of tics (Murphy et al, 2013;Pringsheim et al, 2012;Roessner et al, 2011).…”

“…North American guidelines also suggest the preferential use of alpha-2 agonists over antipsychotics as the first-line pharmacological treatment in children not because of differential efficacy but related to a favorable side-effect profile (Murphy et al, 2013;Pringsheim et al, 2012). These guidelines also suggest the use of behavioral treatments, when available for the treatment of tic disorders, but the availability of behavioral treatments for tic disorders is currently largely confined to select academic centers (Murphy et al, 2013;Pringsheim et al, 2012;Roessner et al, 2011).However, the evidence demonstrating efficacy of the alpha-2 agonists for the treatment of tics is much less substantial than suggested by the guidelines and results of previous systematic reviews. Specifically, although this systematic review (alpha-2 agonists: SMD = À0.54; 95% CI À0.92, À0.16; N = 601) and previous meta-analysis included adult and crossover trials (SMD = 0.31; 95% CI: 0.15-0.48), there was a large amount of heterogeneity between included trials [I 2 = 63% in Whittington et al (2016) when the alpha-2 agonist pill and patch trials are combined] (Weisman et al, 2013).…”

“…Specific guidelines for the treatment of tic disorders in children suggest the use of antipsychotic medications and alpha-2 agonists for the treatment of tics (Murphy et al, 2013;Pringsheim et al, 2012;Roessner et al, 2011). North American guidelines also suggest the preferential use of alpha-2 agonists over antipsychotics as the first-line pharmacological treatment in children not because of differential efficacy but related to a favorable side-effect profile (Murphy et al, 2013;Pringsheim et al, 2012). These guidelines also suggest the use of behavioral treatments, when available for the treatment of tic disorders, but the availability of behavioral treatments for tic disorders is currently largely confined to select academic centers (Murphy et al, 2013;Pringsheim et al, 2012;Roessner et al, 2011).…”