MEDICATIONS AND TOURETTE’S DISORDER:
COMBINED PHARMACOTHERAPY AND DRUG INTERACTIONS

By: Barbara Coffey, M.D., Cheston Berlin, M.D., Alan Naarden, M.D.

Introduction

Tourette Syndrome (TS) or Tourette’s Disorder (DSM IV) is a complex neuropsychiatric disorder characterized by a changing pattern of motor and vocal tics that begin in childhood. Many individuals with Tourette Syndrome have associated non-tic symptoms such as hyperactivity, distractibility, impulsivity, obsessions and compulsions, anxiety, depression, and anger control. These associated symptoms may occur in patterns of frequency or intensity characteristic of an additional comorbid (coexisting) disorder such as Attention Deficit Hyperactivity Disorder (ADHD), Obsessive Compulsive Disorder (OCD), or Oppositional Defiant Disorder (ODD). Whether these problems are an integral part of Tourette Disorder or are separate problems is under investigation. They may result in difficulties in school, in the work place and with social adjustment. Frequently these associated problems or co-morbid disorders are a source of more distress or impairment to the individual with TS than the tics. Not all patients with tics meet the formal diagnostic criteria for Tourette Syndrome but the tics may still have significant intensity to warrant treatment.

Medication Treatment: General Indications

Medication treatment can be beneficial in both reducing the tics and the behavioral and emotional problems in the individual with Tourette’s Disorder or other tic disorders. When symptoms are mild, treatment may include only support, education and monitoring. For symptoms that produce significant distress or impairment, medication treatment may be indicated. Currently there are a variety of medications available for the treatment of tics and the non-tic symptoms. There is no single medication, which is helpful to all individuals with tics or Tourette Syndrome. Tics are often mild and will frequently at least partially remit in many individuals, particularly as they go through adolescence. Often it is the behavioral and emotional features that cause the most difficulty for the child. Tic symptoms that cause interference in the child’s functioning or cause significant distress are targets for medication treatment with the goal of reducing tic severity and frequency. For individuals with mild to moderate tics, specific medications effective for tic reduction include clonidine (Catapres) or guanfacine (Tenex). For individuals with moderate to severe tics, the newer atypical neuroleptics such as risperidone (Risperdal) or older traditional neuroleptics such as haloperidol (Haldol) may be indicated. The decision to use medication should take into account a variety of factors in addition to tic severity such as the child’s age, medical history and past history of response to medication. Typically one medication can be used over period of several months or longer until the tics have abated.

For many individuals, the primary symptoms requiring treatment may be behavioral or emotional, such as hyperactivity, impulsivity or obsessions and compulsions. Medications that target the non-tic symptoms such as antiobsessionals (selective serotonin reuptake inhibitors or SSRIs) or medications for Attention Deficit Hyperactivity Disorder such as methylphenidate (Ritalin), dextroamphetamine (Dexedrine, Adderall), or atomoxetine (Strattera) may be indicated. These medications may or may not have direct effects on the tics, in addition to the effects on the behavioral or emotional symptoms.

Monotherapy or Targeted Combined Pharmacotherapy

If the major symptoms include both tics and behavioral or emotional difficulties, medication may be effective to address both sets of symptoms. The first option is called monotherapy when just one medication is used to address two or more problems; this strategy is recommended if possible as a first choice since it is easiest to use and may have the best compliance. The physician may start with one agent that can address both the tics and the non-tic symptoms such as clonidine for tics and ADHD or clonazepam (Klonopin) for tics and moderate to severe anxiety.

If monotherapy is not possible or has not been effective individuals may require the use of two (or more) medications simultaneously to control both tics and behavioral or emotional symptoms. This approach is called targeted combined pharmacotherapy, referring to the careful, judicious use of more than one medication simultaneously. Although this is a more complicated approach, it has several advantages including 1) using lower doses of each medication, reducing the likelihood of side effects associated with higher doses of single agents and 2) potential augmentation or synergism (booster effects) of combination therapy. Given the increasing recognition of the prevalence and clinical significance of the co-morbid problems in individuals with TS, this approach is becoming more frequent in its use.

Less frequently, more than two medications can be used in the treatment of tics and the co-morbid problems. This is a more complicated approach since the likelihood of interactions between the medications increases as the number of medications used together increases.

continue: Medications To Treat Tics

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Reviewed: 03/2006