Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders

Abstract

ObjectiveTo make recommendations on the assessment and management of tics in people with Tourette syndrome and chronic tic disorders. MethodsA multidisciplinary panel consisting of 9 physicians, 2 psychologists, and 2 patient representatives developed practice recommendations, integrating findings from a systematic review and following an Institute of Medicine-compliant process to ensure transparency and patient engagement. Recommendations were supported by structured rationales, integrating evidence from the systematic review, related evidence, principles of care, and inferences from evidence. ResultsForty-six recommendations were made regarding the assessment and management of tics in individuals with Tourette syndrome and chronic tic disorders. These include counseling recommendations on the natural history of tic disorders, psychoeducation for teachers and peers, assessment for comorbid disorders, and periodic reassessment of the need for ongoing therapy. Treatment options should be individualized, and the choice should be the result of a collaborative decision among patient, caregiver, and clinician, during which the benefits and harms of individual treatments as well as the presence of comorbid disorders are considered. Treatment options include watchful waiting, the Comprehensive Behavioral Intervention for Tics, and medication; recommendations are provided on how to offer and monitor these therapies. Recommendations on the assessment for and use of deep brain stimulation in adults with severe, treatment-refractory tics are provided as well as suggestions for future research.Glossary AAN = American Academy of Neurology; ADHD = attention-deficit/hyperactivity disorder; CBD = cannabidiol; CBIT = Comprehensive Behavioral Intervention for Tics; CBT = cognitive behavioral therapy; DBS = deep brain stimulation; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, 5th edition; EVID = evidence-based conclusions from the systematic review; HRT = habit reversal training; INFER = deductive inferences from other premises; OCD = obsessive-compulsive disorder; PRIN = generally accepted principles of care; RELA = strong evidence from related conditions; THC = δ-9tetrahydrocannabinol; TS = Tourette syndrome; VMAT2 = vesicular monoamine transporter type 2. Recommendation 3aClinicians should ensure an assessment for comorbid ADHD is performed in people with tics (Level B). Recommendation 3bClinicians should evaluate the burden of ADHD symptoms in people with tics (Level B). Recommendation 3cIn people with tics and functionally impairing ADHD, clinicians should ensure appropriate ADHD treatment is provided (Level B).Share your own best practices. Read commentary with expert opinion.Explore results on an interactive world map. NPub.org/NCP/practicecurrentNeurology ® Clinical Practice Now Accepting Applications for Emerging Leaders ProgramApplications are now open for the prestigious Emerging Leaders program, designed to identify, engage, and mentor talent among early-career members interested in future leadership ro...

Treating Tourette Together: An Agenda for Patient-Centered Research Focused on Comprehensive Behavior Therapy for Tics

“…Given this picture, the American Academy of Neurology recently released guidelines recommending CBIT as the first-line treatment for TDs (Pringsheim et al, 2019). This recommendation aligns with prior guidelines from European (Verdellen et al, 2011) and Canadaian (Steeves et al, 2012) working groups.…”

“…Thus, this domain focuses on improving access to assessment and treatment services that have the requisite knowledge and experience to accurately diagnose and effectively treat tic disorders according to the evidence base and consensus expert treatment guidelines (e.g. (Pringsheim et al, 2019)).…”

“…CBIT is certainly not the only treatment option for people with tics, which can complicate treatment decision-making. Medication is the other major evidence-based treatment option for tics, with research supporting the benefit of medications such as α2 adrenergic agonists and antipsychotics (Pringsheim et al, 2019). However, the relative efficacy of CBIT vs pharmacotherapy is understudied, making it difficult for patients and providers to make evidence-informed decisions about treatment sequencing (i.e., whether there is an ideal order for delivering CBIT and medications), combining (i.e., whether particular pairings of CBIT and medication yield greater benefits), and matching (i.e., identifying for whom particular sequences or combinations of CBIT and medication are most effective).…”

“…Typically, the first important question faced by newly diagnosed patients is whether to intervene at all. The American Academy of Neurology's current practice parameters recommend "watchful waiting" for individuals who do not experience any tic-related functional impairment (Pringsheim et al, 2019). This recommendation is based on research indicating that tics may naturally improve with time for some.…”

Safety and efficacy of taurine as an add‐on treatment for tics in youngsters

“…Antipsychotics are mainly used in patients with tics as the main functional impairment [9,10]. Haloperidol, aripiprazole, risperidone and tiapride have been identified to be effective on tics [9][10][11]. However, there is insufficient evidence to determine the relative efficacy of these drugs [9,10,12].…”