Depts.washington.edu

This publication is intended to provide information about Tourette Syndrome, its management and medications currently
in use. Families are advised to consult a physician concerning all treatments and medications.
Tourette Syndrome (TS) or Tourette’s disorder (DSM
expertise and the time to do the evaluation and be able IV-TR) is a childhood onset, brain-based disorder to start and monitor medication treatment. The evalu- characterized by persistent motor and vocal tics that ation should at minimum identify problems related to last for more than one year. Tics are brief, meaningless tics and any co-occurring conditions. Other important movements or sounds, but can be more complex and components of a good evaluation include the patient’s appear purposeful. In addition, many people with TS general health, family history of any medical and psy- have other problems that might include one or more chiatric problems, treatment history including which of the following: difficulties with attention, learning, medications the person is taking currently or might compulsive behavior, anxiety, irritability, depression, have taken in the past. A thorough evaluation is a criti- impulsivity and aggression. The challenge of living cal first step for making good medication choices. with tics and co-occurring problems can often lead to poor functioning in school, in the work place and dif- The next step is a discussion with the clinician ficulty with social adjustment. For many, medication about the results of the evaluation, the plan for treat- treatment for tics and these co-occurring problems can ment and available treatment options. This discus- be very helpful in reducing symptoms and improving sion should focus on the problems identified and the reasons for deciding on a particular treatment plan. Although people with tics tend to pursue treatment when symptoms are significant, it is important not to be in too much of a hurry. Some tic exacerbations may resolve in time and therefore may not require treatment Even though medications can be helpful in reducing tic with medication (e.g. tic increases due to excitement severity, most people with TS will not require prescrip- during holidays or vacations). It is worth the time it tion medications for their tics. The need for medication takes to make a good decision about whether or not to depends on the severity of tic symptoms, the presence of co-occurring problems and the person’s overall func-tional capacity. For example, those with very frequent The final step is the actual treatment trial — a tics, but who are not distressed by them, may not want process of finding the best dose with the fewest side or require medication. On the other hand, some with effects. Most clinicians begin medication with a low less severe symptoms may experience impairment in dose and increase the dose over time in order to reduce social, school or work functioning and elect to pursue tic severity while keeping medication side effects to a medication treatment. Ultimately, the decision about minimum. It is extremely important when beginning whether or not to start a medication should take these medication to report both the benefits and side effects realities into account. Even though not everyone may to the clinician so that the best and safest dose of medi- need medication for their tics, it is important for every- one to know what the treatment options are.
Although everyone would like to take the lowest possible effective dose of medication, sometimes higher General Principles of Medication Treatment doses may be necessary and should not, in principle, be avoided or cause undue concern. Finding the best dose of medication for a child can be more complicated than Prior to starting medication it is important to find a for adults. Although children often use lower doses qualified clinician (e.g. physicians, nurse practitioners than adults, parents should not automatically assume and psychologists) for an evaluation. Although many that children always require low doses of medication. clinicians can provide evaluation and treatment ser- Actually, children sometimes require doses similar to vices, it is important to identify a clinician who has the those of adults or even higher. It is advisable to work with clinicians experienced in treating children and problems first may be helpful in ways that the child who are aware of such differences and take them into and family hadn’t initially considered. By addressing account when prescribing medication. With the right these problems first, functioning at school and at home clinician a medication trial can be accomplished -- even might improve and make it less likely that the tics will Because most medications do not show benefit Those coping with both tics and another co-oc- immediately, the pacing of dose adjustments is also curring problem may require treatment for both condi- important. Taking too long to increase the dose of tions. Sometimes addressing two (or more problems) a medication may unnecessarily prolong suffering; may require a treatment plan that includes two (or increasing doses too quickly may inadvertently over- more) medications. While it is always simplest to use shoot the effective dose and increase the risk of side one medication, taking two medications to treat two or effects. Once an optimal medication dose is identified, more problems is routine practice, and should not cause ongoing monitoring is required to assess for continuing undue concern. That said, while careful monitoring benefit, side effects and adherence to the medication and good communication are important when on a sin- gle medication, these precautions are critically impor-tant when medication combinations are prescribed. After a period of successful treatment, the clini- cian may suggest reducing the dose of medication in Some people with TS lead very difficult lives. At order to identify the lowest dose that is necessary to times their difficulties are caused by their symptoms, maintain good tic control. Because tic symptoms rou- sometimes by how others treat them, and sometimes tinely wax and wane and improve over time, periodical- their problems are due to the decisions and choices ly reducing the dose of medication is an important part they make for themselves. Although this brochure of tic treatment. Almost all tic suppressing medications focuses on medication treatment, it is very important should be reduced slowly to find the lowest effective to note that not all the problems a person with TS dose. A slow reduction in medication is particularly faces can be resolved by taking medication or reducing important for those who have been on tic suppressing tic symptoms. Actually, psychological treatments may medications for an extended period of time. The same be the most important and valuable first treatment step goes for discontinuing medication; the dose should be reduced slowly and then stopped, and never stopped
abruptly. Stopping tic suppressing medications abrupt-
ly can actually cause tics to worsen in a way that would
Where Can One Get Good Information about not otherwise occur with a more gradual reduction in dose. Some patients actually develop transient motor movements called “withdrawal dyskinesia” from dis-continuing medication too quickly. Your clinician will For information about specific medications, there are prescribe a safe step-by-step program for decreasing quite a few helpful resources. Perhaps the easiest way to dosage until the medication is discontinued completely.
access information about medications is from reputable sources on the Internet. A drug manufacturer’s website Problems that co-occur with TS may also respond provides specific product information that has been to medication. At the end of the evaluation, it is not reviewed and approved by the U.S. Food and Drug uncommon for people with TS to become more aware Administration. This is the same information that is of just how these co-occurring problems have been in the Physicians’ Desk Reference (PDR) and is the impacting their lives. If co-occurring problems are basis of the information provided by pharmacists with more impairing or distressing than the tics, clinicians every prescription. A medication’s product informa- may suggest that the co-occurring problems be treated tion is usually of very high quality, but not always easy first rather than treating the tics. For example, a child to read and understand. MedlinePlus website http:// with mild to moderate tics may have more significant medlineplus.gov is a public service provided by the problems with attention and concentration at school, U.S. National Library of Medicine and the National or anxiety and fears at home. Treating these other Institutes of Health. This website provides basic infor- suppressing will refer to their use for other conditions mation about prescription and over-the-counter medi- without mentioning their usefulness in treating TS. cations as well as some herbs and supplements. The The information below describes basic information information is presented in a straightforward, easy-to- about how these medications are commonly prescribed read manner and is prepared by the American Society of Health-System Pharmacists based on information from the U.S. Pharmacopea and MedMaster® drug Antipsychotics
information database. Because most medications used for tic suppression are marketed for other medical con- Antipsychotics are the most effective group of medi- ditions, there is usually limited information about how cations for reducing tic severity. They are classified these medications work in TS. Therefore, textbooks on as major tranquilizers or antipsychotic medications TS and review articles about TS in the medical litera- because they are generally prescribed for hallucina- ture can be very helpful in clarifying how medications tions, delusions and problems with thinking and orga- nization in people with psychosis. These medications have also been categorized as antiemetics because they Although other websites may be helpful as well, it can be effective in reducing severe nausea and vomiting. is important to “consider the source” and not be unduly There are a number of medications considered to be influenced by websites that are less than reputable. It part of the antipsychotic class, and most of these have is important to remember that there are some people and organizations that have very strong opinions about using medications to address medical and behavioral Antipsychotic medications are thought to be problems. Some of these websites provide information helpful for TS symptoms because of their ability to that is not necessarily based on scientific evidence and decrease dopamine function in the brain. Dopamine is the information posted may even employ “scare tactics” a neurotransmitter--a brain chemical--which is involved to influence people about the safety and efficacy of spe- in nerve cells communicating with each other. Some antipsychotics have a lot of specific power to reduce dopamine functioning and some have less power. Antipsychotics also differ in their impact on other brain neurotransmitters (e.g. serotonin, norepineph-rine, acetylcholine). The effect of a specific antipsy- The medications used for reducing tic severity or treat- chotic on dopamine and other neurotransmitters will ing co-occurring conditions come from different drug impact the medication’s possible benefits as well as its classes. Within each class there are a number of medi- cation options a clinician and patient might choose. That is why, individuals with TS and their families Antipsychotic medications with proven efficacy for should discuss with their clinicians the specific symp- reducing tic severity include the typical antipsychot- toms to be targeted for medication treatment and the ics haloperidol (Haldol®), pimozide (Orap®), and the specific medication to be used. The following section is atypical antipsychotic risperidone (Risperdal®). Others organized by class of medication and then within each antipsychotics may also be helpful [e.g. fluphenazine class are the specific medication options. (Prolixin®)] even if they have not been specifically stud-ied in TS. In general, antipsychotics with the greatest Tic Suppressing Medications
dopamine blocking activity are the most effective for reducing tics. However, the decision about which medi- There is no medication that has been discovered or cation a person should take depends on which medica- developed specifically for the purpose of reducing tic tion may benefit the specific patient best. Clinicians severity. Rather, medications developed to treat other may suggest using a medication other than one with a medical and psychiatric conditions have been later long track record because balancing the benefit and side found to be helpful in reducing tics. As a result, most effects may fit the individual better than medications of the published information about medications for tic Reducing dopamine function is helpful for reduc- In addition to the common side effects of antipsy- ing tic severity, but reducing dopamine function may chotics described above, it is important to know about also result in unwanted effects on motor control such two very uncommon, but significant complications of
as stiffness, slowed movements and unwanted muscle antipsychotic treatment--tardive dyskinesia and antip- contractions (i.e dystonic reactions, tremor and rest- sychotic malignant syndrome. Discussing these compli- lessness).These side effects are common enough that cations of antipsychotic treatment in this brochure does people should be aware of them and understand the not mean that they are likely to occur; rather they are
best way to manage them. They are all reversible either described here to put the risk of these side effects into by reducing the dosage, or in some cases by discontinu- perspective and allay concerns of individuals who may ing the medication. Moreover, some of these motor side effects can be controlled by taking anticholinergic medications such as benztropine (Cogentin®), diphen- Tardive dyskinesia is a motor side effect of chronic hydramine (Benadryl®) and trihexyphenidyl (Artane®). antipsychotic treatment which is rare in individuals Anticholinergic medications may be started with a with TS, but more common in individuals treated antipsychotic to prevent the development of unwanted chronically with antipsychotics for psychosis. Tardive motor side effects, or given after motor side effects dyskinesia tends to be a more continuous movement develop to reduce discomfort. Similarly, because antip- problem than tics which tend to be brief and episodic. sychotics are tranquilizers and reduce agitation for Features of tardive symptoms can include the inability people with psychosis, they may be too tranquilizing to hold the tongue or mouth still (i.e. chronic worm- for people with TS, resulting in sedation or reduced like or chewing movements). Writhing movements of the arms, legs, and trunk may also occur. When the hands are affected, the person may appear to be play- In general, the dose of antipsychotic used to treat ing an invisible guitar or piano. Tardive dyskinesia psychosis is considerably higher than doses used for tic may emerge during extended treatment with antipsy- suppression. A dose of antipsychotic for tic suppression chotics or may occur when the antipsychotic dosage is may range from 5-30% of the daily dose required for reduced after long term treatment. There is no specific psychosis. There are always exceptions to such general treatment for tardive dyskinesia. When symptoms statements, but usually, high doses of antipsychotics for are identified, medication discontinuation is recom- tic suppression are not more helpful than lower doses, mended unless the medication is absolutely critical to cause more side effects and therefore are not recom- maintain functioning. Because it can be difficult to dis- tinguish some complex tics from symptoms of tardive dyskinesia, a movement disorder specialist should be To improve the treatment for psychosis and to consulted when it is suspected that a person with TS decrease the risk for motor side effects, atypical antip- has developed tardive dyskinesia after treatment with sychotics were developed. Atypical antipsychotics have relatively less impact on dopamine and more impact on other neurotransmitter systems. Because of the lesser Antipsychotic malignant syndrome (NMS) is a effects on dopamine, atypical antipsychotics may be a very rare and potentially serious complication of antip-
better choice for people with TS who are sensitive to sychotic treatment. Although the cause is unknown, motor side effects caused by the typical antipsychot- the symptoms of NMS are consistent with nearly ics. In addition, atypical antipsychotics may impact complete blockage of dopamine function that leads to other neurotransmitter systems as well, resulting in severe muscle rigidity, fever, seizures, muscle break- a broader range of benefits (e.g. improved mood or down and kidney failure. When identified early, NMS impulse control) for people with TS. Although atypical can be effectively treated. If NMS symptoms are not antipsychotics may have less risk for motor side effects, recognized and not addressed appropriately, they can some appear to increase appetite and cause weight result in death. It must be emphasized that NMS is gain. Recently there has been increasing concern about extremely rare in individuals with TS and that clini-
antipsychotic-induced weight gain being associated cians are specifically trained to observe for the signs with the development of metabolic problems including of NMS. Therefore, concerns about NMS should not non-insulin dependent diabetes (i.e. type II diabetes) result in rejecting a trial of antipsychotics for tic sup- Alpha Adrenergic Agonists
Medications Not Wel -Studied for Reducing
Tic Severity
Another class of medications commonly used for tic suppression are the Alpha Adrenergic Agonists — Many other medications have been prescribed to clonidine and guanfacine (Catapres® and Tenex® respec- individuals with TS to reduce tic severity. However, tively). These medications are marketed to control high these medications are less well established and there- blood pressure, but have been prescribed for a number fore less commonly used. One problem with evaluating of other conditions, including drug withdrawal syn- whether a medication is effective in reducing tics is the dromes and tics. Exactly how alpha adrenergic agonists fact that tics wax and wane over time. As most people reduce tic severity is not known, but it may be related tend to seek treatment when their symptoms are at to decreased central nervous system arousal. their worst (people don’t go to the clinician when all is well), it is not uncommon for people to experience Dosages of alpha agonists for tic symptoms are some decrease in tic symptoms right after visiting their usually lower than those used in the treatment of high clinician--even when no treatment has been prescribed. blood pressure. Because alpha agonists are short acting, Therefore, a person beginning medication may falsely for optimal tic control multiple doses throughout the attribute the reduction in tics to the effects of the day (2-4 doses) may be required. Although some people medication, rather than to the natural course of the with TS may have a fairly dramatic response to alpha disorder. For this reason most clinicians are skeptical agonists, most experience more modest benefit than of reports about a single person doing very well on a what is usually observed when taking antipsychotic newer or less established treatment. Understandably, medications. On the other hand, the side effect profile clinicians are more confident about treatments that of the alpha agonists is milder than that of the anti- have proved effective in well-designed scientific studies. psychotics. The most common side effect is sedation which can occur even at fairly low doses. Some chil- Clonazepam (Klonopin®) is a minor tranquilizer dren on alpha adrenergic medications have exhibited used in the treatment of anxiety, seizures and bipolar disorder and has been studied and found to be helpful for tic suppression. Reducing anxiety in people with As described below, alpha agonists can also be TS may in and of itself reduce tic severity. helpful in treating Attention Deficit Hyperactivity Disorder (ADHD). The combination of modest benefit Early studies of nicotine in the form of a skin for tics and ADHD plus a better side effect profile patch or chewing gum and nicotine blocking medica- than antipsychotics is why some clinicians choose alpha tions such as mecamylamine (Inversine®) were both agonists first when prescribing medication to treat chil- found to be to be helpful in reducing tics. However, subsequent definitive studies have not borne out the initial enthusiasm for these treatments. Baclofen (a Both clonidine and guanfacine come in a patch muscle relaxant), tizanidine (used to treat muscle form. When attached to the skin, the patch releases the spasticity), and topiramate (used for seizures) may be medication into the blood stream more gradually than helpful for tics, but further, more definitive evaluation pills thus providing more convenient dosing and consis- tent medication effects. The patch option decreases the need for pill taking multiple times each day, and may have fewer side effects than the pill form. However, some people develop a skin rash at the site of the patch prompting discontinuation. Table 1. Medications used in the Treatment of Tics Typical Antipsychotics
Medication
Usual Starting
Usual Treatment
Comments
Dose
Dose
Haldol®
for tics. Often not used as the first medication for tic suppression due to side effects.
effects make pimozide a second choice for tic suppression.
Similar to haloperidol, but some believe Prolixin®
it has a milder side effect profile. A good first choice typical antipsychotic for tic suppression.
Tiapridex
Tiapridal
(Belgium, France, Spain, Holland, Switzerland)sulpiride Dogmatil
Sulpital
Sulparex
(UK, Europe)
Atypical Antipsychotics
risperidone
Probably the best atypical antipsychotic Risperdal®
for tic suppression. May have less risk for motor side effects than haloperidol and fluphenazine. May also benefit impulse control and aggression. Weight gain can be a significant problem in some patients.
Invega®
Geodon®
for the development of weight gain. Unclear how helpful it is for tic suppres-sion. Lowest available dose is 20 mg. Studies of ziprasidone had other dose preparations available that are not avail-able currently.
Zyprexa®
weight gain is greater than risperidone.
Seroquel®
studied in TS and unclear on how effec-tive it is for tics. Dosing is not estab-lished.
Abilify®
nism of action. Studies are currently underway. Appears promising as a tic-surpressing medication but dosage is not yet established.
Recently available in the United States.
Xenazine®
Nitoman®
Adrenergic Agonists
clonidine
Catapres®
tic suppresion. Not consistently as effec-tive as antipsychotics for tic suppression. Also helpful for ADHD.
Same as clonidine tablets, localized skin Catapres® patch
Tenex CR®
choice fo tic suppression in children with ADHD.
Benzodiazepines
clonazepam
Some potential for developing tolerance. Klonopin®
Slow tapering may be required for dis-continuation.
Stimulants for TS Plus Attention Deficit
attributing such worsening to having begun to take a Hyperactivity Disorder
medication. Although it appears that stimulants can be used safely in people with tics and ADHD, the product The most commonly used medications for Attention labeling of methyphenidate and amphetamine products Deficit Hyperactivity Disorder (ADHD) are central discourages using stimulants in people with tics or nervous system stimulants which contain the chemical people with a family history of tics. Although scientific compounds methylphenidate (e.g. Ritalin®, Concerta®, studies do not necessarily support this concern, it is Metadate® and Methylin®), dextroamphetamine highly unlikely that the labeling will change. As you (Dexedrine® and Dextrostat®) and mixed amphetamine can imagine it is difficult for a pharmaceutical company salts (Adderall®). Stimulants have proved effective for to remove warnings from their labeling as it may make ADHD symptoms in children with and without TS. them more vulnerable to lawsuits. For children with Common side effects of stimulants include appetite tics and ADHD whose clinician has recommended a suppression and difficulty falling asleep. One of the stimulant, it is important to know that the evidence greatest drawbacks of stimulant medications is their base for safety and the product information for stimu- short duration of action. To have maximum benefit, children with ADHD may have to take medication multiple times each day including at school. To address Lastly, recent media reports and U.S. Food and this drawback the pharmaceutical industry has devel- Drug Administration hearings have alerted all to the oped new longer acting preparations to extend the risk of stimulants in children with known heart defects duration of benefit thus making stimulants more useful and also to the worsening of symptoms of other psy- for people over the course of a day.
chiatric disorders. It is important before beginning to take stimulants that the prescribing clinician be aware In the late 1970’s and 1980’s there were numer- of the patient’s personal and family history of cardiac ous published reports that children taking stimulants developed new onset tics or experienced worsening tics. One confounding factor regarding stimulants “causing” Non-Stimulant Medication for ADHD
new or worsening tics is the fact that ADHD symp- Treatment
toms often emerge before the development of tics. So if stimulants are begun for ADHD and then tics appear, Because of past concerns about the association of it is difficult to know whether the tics are “caused” stimulants with the emergence of new tics or the wors- by the stimulant, or whether the onset of tics would ening of current tics, clinicians have sought alternative have occurred anyway as part of the natural course of medications to treat ADHD symptoms. Perhaps the the tic disorder. Whether stimulants actually cause most common alternatives are clonidine and guanfa- tic worsening can be determined in a research study cine. Both have proved effective in reducing both tic by comparing the rates of tic worsening in subjects on severity and ADHD symptoms. Common side effects medication vs. placebo. In such studies, tic worsening of these two medications include sedation and irrita- has not occurred more commonly in those on stimu- bility. Another medication with an FDA indication lant medication compared to placebo. Interestingly, for ADHD is atomoxetine (Strattera®). Atomoxetine the Tourette Syndrome Study Group’s study compar- is a norepinephrine reuptake inhibitor that has dem- ing methylphenidate to clonidine and placebo showed onstrated efficacy for ADHD in children with tics. similar rates of tic worsening (approximately 20-25%) Common side effects of atomoxetine include sedation, in each group. The lack of a difference between meth- gastrointestinal upset and irritability. In the past, tri- ylphenidate and placebo suggests there is no risk for cyclic antidepressants were found useful for ADHD tic worsening that can be specifically attributed to tak- in children with and without tics. A number of case ing the stimulant methylphenidate. It is important for reports of sudden death in children taking desipramine the clinician, parents and the child to pay attention to in the early 1990’s has had a significant negative impact how frequently tics worsen after starting medication on the number of clinicians prescribing this medica- treatment. All should be aware that tic worsening is tion for ADHD. While there are theories about why something that might occur during any treatment with tricyclic antidepressant might have been a contributing any medication, even placebo, and to be careful about factor in these deaths there is no proven causal link. Table 2. Medications used in the treatment of co-occurring ADHD and TS
Medication
Usual Starting Usual Treatment
Comments
Dose
Dose
Antidepressants
imipramine
A tricyclic antidepressant less commonly used Tofranil®
today due to poor tolerability and risk for electrocardiogram changes especialy in chil- dren. May have benefits for ADHD, anxiety and depression. Helpful for sleep problems in Shown to be effective in children with ADHD Norpramin®
and TS, but risk for electrocardiogam changes Pamelor®
A novel antidepressant with a unique mode Wellbutrin®
of action. Effective in ADHD, but benefit is Wellbutrin XR®
smaller than stimulants Risk for seizures if Wellbutrin SR®
Stimulant medications
methylphenidate
Commonly used stimulant available in short Ritalin®
and long-acting preparations. Short acting Ritalin SR®
preparations may require midday and late Ritalin LA®
afternoon dosing. Longer acting compunds Methylin®
may require 1-2 doses per day depending on Methylin ER®
the preparation. Common side effects include Concerta®
decreased appetite, insomnia and irritability.
Metadate®
Metadate ER®
Metadate CD®
dexmethylphenidate
Focalin®
dextroamphetamine
Commonly used stimulant with both short and Dexedrine®
DexePatch®
methylphenidate in efficacy and side effects.
Dextrostat®
Dexedrine® spansules
amphetamine salts
A combination of four different d-amphet- Adderall®
amine and l-amphetamine compounds. Similar Adderall XR®
to dextroamphetamine and methylphenidate in lisdexamfetamine
Vyvanse ®
Norepinephrine
reuptake inhibitors
atomoxetine
A unique medication for ADHD based on its Strattera®
effects on norepinephrine. Dosing in chldren is based on weight. Common side effects include sedation, stomach upset, vomiting and irritabil- ity. May require several weeks for dose adjust- ment to maximize benefit and minimize side SSRIs and other Antidepressants
for drug interaction are better for someone sensitive to side effects and are already on other medications. A class of antidepressant medications found useful While SSRIs are generally well tolerated some people when treating Obsessive Compulsive Disorder (OCD), early in the course of treatment may feel activated or other anxiety disorders and depression are the Selective agitated, have gastrointestinal side effects or headaches. Serotonin Reuptake Inhibitors (SSRIs). Most of these These side effects can be managed by reducing the are approved for use or have demonstrated safety and dose and in some cases, discontinuing the medication. benefit in children and adults with OCD down to as Clomipramine is a tricyclic antidepressant that is also young as age 6 years. Unlike stimulant medications useful in treating OCD in children and adults because that work almost immediately, antidepressant medica- tions often take from 2-4 weeks of treatment to begin to be effective. To maintain benefit over time requires Although not common, antidepressants, including that the person take the medicine consistently at an the SSRIs, can also induce manic reactions (e.g. eupho- effective dose. Extended treatment with antidepres- ria, grandiosity, decreased need for sleep and increased sants 9-12 months minimum may be necessary for interest and involvement in high risk activities). This ongoing control of symptoms. Too low a dose and/or worrying complication may require management by too short a duration of treatment are the primary rea- a psychiatrist experienced in treating people with sons for poor outcomes with antidepressants. bipolar disorder. More recently the Food and Drug Administration has warned that about 2% of young The various SSRIs differ both in their half-life people treated with antidepressants may experience (i.e. how long it takes for the body to reduce the blood an emergence or worsening of suicidal thoughts and level by half) as well as their potential for drug inter- behaviors. Your clinician is the best person to help you actions. Long half-life SSRIs take longer to leave the understand whether the potential benefit of medication body after discontinuation, but they are also more sta- outweighs this small potential risk. Clinicians, patients ble when doses are missed. Short half-life SSRIs clear and their families need to know about all risks, includ- from the body more quickly if side effects develop, but ing the risk of not treating anxiety and depression, may be less effective when doses are missed. Clinicians and be vigilant early in the course of treatment for the often weigh these factors when recommending an unexpected emergence or worsening of depression or SSRI. For example, short acting SSRIs with a low risk Table 3. Antidepressants for OCD, Anxiety and Depression
Medication
Usual
Usual
Comments
Starting Dose
Treatment
Dose
Serotonin reuptake
inhibitors
fluoxetine
The SSRI with the longest half-life and highest Prozac®
potential for interacting with other drugs. Only SSRI approved by the FDA for use in children The half-life of paroxetine gets longer with repeated dosing. Similar to fluoxetine in benefits, side effects and drug interactions. Paroxetine may be more often associated with sedation, weight gain and withdrawal reactions than other SSRIs.
A SSRI with a short half-life and fewer potential Zoloft®
drug interations than fluoxetine. However, the product labeling advises against combining sertra- One of the first SSRIs with demonstrated effici- cacy in childhood and adult OCD. A short acting SSRI with a different drug interaction profile than fluoxetine, paroxetine and sertraline.
A medium duration half-life with similar side Celexa®
effect profile to the other SSRIs. Lower likeli- hood for drug interactions than fluoxetine and Citalopram consists of two mirror image com- Lexapro®
pounds called isomers. Escitalopram is the medicinally active form of the two compounds. Escitalopram has a medium half-life and a side effect profile similar to the other SSRIs.
A tricyclic antidepressant with serotonin enhanc- Anafranil®
ing properties. Useful in OCD. It is not as selec- tive for serotonin as the SSRIs and has more side effects, but may be useful for those with OCD who have trouble sleeping. Combining clomip- ramine with some SSRIs may increase risk for side effects and decrease its efficacy.
Norepinephrine
reuptake inhibitors
venlafaxine
Has both serotonin and norepinephrine enhanc- Effexor®
ing properties useful in severe depression. Side Effexor XR®
effects similar to the SSRIs but may increase blood pressure especially at higher doses.
Has both serotonin and norepinephrine effects. Cymbalta®
New to the market and no information about use Modern technology and high quality control in the Tic symptoms range from mild to severe with most generic pharmaceutical manufacturing industry guar- people experiencing mild symptoms; many individu- antee that generic medications are effective. However, als never require medication treatment for their tics. generic medications may not be exactly the same as However, people with tics may have other prob- their brand name counterparts. Some individuals lems that can benefit from medication treatment. switching to generics from brand name products or Sometimes treating the co-occurring conditions is more switching from one generic to another have reported helpful than treating the tics. Lastly, not all problems experiencing no problems. And yet, others have found faced by people with TS require medications and may the generics to be less effective than the brand name actually be better addressed with psychological inter- products. In general, it is recommended to be consis- ventions. Before starting any treatment a good evalua- tent when taking either the brand name medication tion is key to maximizing the chance that a treatment or generic. In other words, it is not advisable to switch plan will be successful. The TS research community back and forth between brand name medications is working actively to discover new and better treat- and generics or even among generics. Individuals are ment programs. Until that time, the currently available encouraged to discuss this issue carefully with their medications can be helpful to many individuals with In this brochure the author has made every effort to provide the best available information about medications commonly used to reduce tic severity and treat conditions commonly co-occurring in Tourette To meet the pharmacological treatment needs of adults Syndrome. This information is not meant to be and children with TS requires a very careful assess- exhaustive and does not reflect the rapidly changing ment, identification of the most impairing condition nature of medical treatment for TS and co-occurring — be it tics or co-occurring conditions or behaviors conditions. Rather the goal has been to provide a basic — and a careful matching of the medication treatment introduction to medication treatment in general, stimu- to the specific problems identified. A good doctor- late readers to learn more about medication treatment, patient relationship is critical to the success of any and to enhance communication among physicians pharmacological treatment effort. People are encour- and the people with TS whom they treat. Readers are aged to become knowledgeable about the medication cautioned against taking and/or changing medications they take and communicate fully with their clinicians. based on information in this pamphlet (or any other They should become active participants in their own source) without first consulting their physicians.
treatment and follow-up so as to maximize benefit and minimize any adverse consequences of medication treatment. Lastly, it is important to understand that any medication not taken surely cannot be very effec-tive. Taking medication as it is prescribed is critical to optimal outcomes. TSA gratefully acknowledges the counsel and guidance Carol Mathews, M.D.
of its Medical Advisory Board. Members of the TSA Medical Advisory Board welcome queries from col- leagues and other professionals and can be reached by contacting the Tourette Syndrome Association, Inc.
Tanya Murphy, M.D.
McKnight Brain Institute
John T. Walkup, M.D., Chairman
Johns Hopkins University School of MedicineBaltimore, MD Paul Sandor, M.D.
University of Toronto
Cheston M. Berlin, Jr., M.D.
The Milton S. Hershey Medical CenterHershey, PA Lawrence Scahill, MSN, Ph.D.
Yale Child Study Center
Cathy Budman, M.D.
North Shore University Hospital Manhasset, NY Douglas W. Woods, Ph.D.
University of Wisconsin
Leon S. Dure, M.D.
Samuel H. Zinner, M.D.
University of Washington School of Medicine
Donald L. Gilbert, M.D., M.S.
Cincinnati Children’s Hospital Cincinnati, OH Jorge L. Juncos, M.D.
Emory University School of MedicineAtlanta, GA John T. Walkup, M.D
Katie Kompoliti, M.D.
Chair, TSA Medical Advisory Board, Professor, Rush Presbyterian/St. Luke’s Medical Center Division of Child and Adolescent Psychiatry, Johns Hopkins Medical Institutions, Baltimore, MD James T. McCracken, M.D.
I wish to thank Lawrence Scahill, MSN, Ph.D. for his valuable assistance in the writing of this publication. This publication is an adaptation of a previous one written by Dr. Gerald Erenberg, M.D., former chair of the TSA Medical Advisory Board.
Permission to reprint this publication in any form must be obtained from the national Additional TSA resources - Videos & Vignettes
HBO Documentary ”I have Tourette’s But Tourette’s Doesn’t Have Me”
HBO documentary originally aired November 12, 2005. Childen with TS. 27 min. plus 30 min. extras.
AV-9 After the Diagnosis . . . The Next Steps
Produced expressly for individuals and families who have received a new diagnosis of TS. This video was developed to help clarify what TS is, to offer encouragement, and to dispel misperceptions about having TS. Features several families in excerpts from the Family Life With TS A Six-Part Series who recount their own experiences as well as comments from medical experts. Narrated by Academy Award Winner Richard Dreyfuss. 35 min.
AV-10 The Complexities of TS Treatment: A Physicians’ Roundtable
Three internationally recognized TS experts, Drs. Cathy Budman, Joseph Jankovic and John Walkup provide colleagues with valuable information about the complexities of treating and advising families with TS. Emphasis is on different clinical approaches to patients with a broad range of symptom severity. Co-morbid and associated conditions arecovered. 15 min.
AV-10a Clinical Counseling: Towards an Understanding of Tourette Syndrome
Targeted to counselors, social workers, educators, psychologists and families, this video features expert physicians, allied professionals and several families summarizing key issues that can arise when counseling families with TS. Includes valuable insights from the vantage point of those who have TS and those who seek to help them. 15 min.
AV-11 Family Life With Tourette Syndrome . . . Personal Stories . . .
A Six-Part Series
Adults, teenagers, children, and their families . . . all affected by Tourette Syndrome describe lives filled with triumphs and setbacks . . . struggle and growth. Informative and inspirational, these stories present universal issues and resonate with a sense of hope, possibility, and love. 58 min.
An up-to-date Catalog of Publications and Videos

Source: https://depts.washington.edu/dbpeds/A%20Guide%20to%20TS%20Medications_M-313.pdf