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DrKkhan

tourettes treatment

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haloperidol or clonidine?

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depends on the context. 

Tics are supressed by Dopamine antagoinsts more than others. hence antipsychotics are the choice but clonidine can also be used in co mobidity 

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For "uncomplicated", mild to moderate cases, Clonidine should be tried first. 

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For "uncomplicated", mild to moderate cases, Clonidine should be tried first. 

 

Treating tics

Although a wide range of medications has been used to treat tics, there have been relatively few published RCTs of their use. Until recently, haloperidol, pimozide and, in the UK, sulpiride, were the mainstays of treatment. In RCTs, all three have been shown to be efficacious in reducing tics. Haloperidol is the most efficacious, leading to improvement in approximately two-thirds of cases, with pimozide and sulpiride improving tics in just over one-half. However, haloperidol is associated with frequent adverse reactions including disabling extrapyramidal effects. Pimozide, although associated with fewer adverse events than haloperidol, can lead to ECG abnormalities, particularly prolongation of the QT interval. Sulpiride is also associated with a lower, but not absent, rate of extrapyramidal side-effects.

Recently, there has been much interest in the potential use of the atypical antipsychotics in treating Tourette syndrome. The increase in their use outstripped the available evidence and was based on case reports and case series rather than RCTs. However, over the past 2 years, RCTs have begun to appear in the literature. Sallee et al(2000) demonstrated that ziprasidone was superior to placebo and, at a mean dose of 30 mg/day, was efficacious in reducing tics by an average of 35% in a group of 28 children and adolescents with moderate-to-severe tic symptoms. Dion et al(2002) found that risperidone, at a median dose of 2.5 mg/day, was significantly superior to placebo in reduction of tics, with 60% in the risperidone group showing clinically significant improvements. Risperidone did not increase symptoms of obsessive–compulsive disorder. Bruggeman et al(2001) compared risperidone and pimozide in a comparative double-blind parallel-group study. At the end-point, 54% of the patients on risperidone and 38% of those taking pimozide were rated as having only very mild or no symptoms. Both treatment groups had improved significantly with regard to Global Assessment of Functioning and Clinical Global Impressions scale outcomes. Symptoms of anxiety and depressive mood had also improved significantly from baseline in both groups but improvement in obsessive–compulsive behaviour reached significance only in the risperidone group. Finally, Onofrj et al(2000) reported the results of a very small 52-week double-blind crossover study of olanzapine v. low-dose pimozide in four adult patients. Although the size of the trial prevents detailed conclusions being drawn, it suggested that olanzapine was as efficacious as pimozide, with all four patients opting for olanzapine at the end of the study. All studies reported that the atypicals were associated with few adverse events, but larger, longer trials are needed before firm statements on safety can be made. Clinical experience suggests that a significant number of patients are unhappy about the amount of weight they gain while taking these drugs, although many commentators believe that the atypicals will soon become the first-line treatment for tics.

Other pharmacological treatments for tics include: α-agonists such as clonidine and guanfacine; botulinum toxin; calcium antagonists such as nifedipine, flunarizine and verapamil; nicotine; and the selective androgen receptor antagonist, flutamide. All received some support in open use for decreasing tics. However, of these only flutamide has been shown in an RCT to reduce tics. The studies involving these drugs are helpfully summarised by Robertson & Stern (2000). Clearly, there still needs to be much more research into drug treatments of Tourette syndrome, including larger trials from which clinicians can truly plan treatment in an evidenced-based way.

 

http://apt.rcpsych.org/content/9/4/289.full?sid=29a2bb86-3327-425d-b5ee-a04a44e9fcd9

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