Tamara Pringsheim, Michael S. Okun, Kirsten Müller-Vahl, Davide Martino, Joseph Jankovic, Andrea E. Cavanna, Douglas W. Woods, Michael Robinson, Elizabeth Jarvie, Veit Roessner, Maryam Oskoui, Yolanda Holler-Managan, John Piacentini. Practice guideline recommendations summary: Treatment of tics in people with Tourette syndrome and chronic tic disorders. Neurology May 2019, 92 (19) 896-906
Objective To make recommendations on the assessment and management of tics in people with Tourette syndrome and chronic tic disorders.
Methods A 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.
Results Forty-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.
From the manuscript
People with tics receiving CBIT are more likely than those receiving psychoeducation and supportive therapy to have reduced tic severity (EVID). CBIT is a manualized treatment program consisting of habit reversal training (HRT), relaxation training, and a functional intervention to address situations that sustain or worsen tics (RELA).13 The child and adult CBIT trials demonstrated the efficacy of an 8-session protocol, though cases complicated by poor tic awareness, treatment motivation, more severe tics, or substantial clinical comorbidity may benefit from a longer course of therapy. Most children (aged 9 years or older) and adults showing an initial positive response to CBIT will maintain their treatment gains for at least 6 months (EVID). CBIT can be effective for children younger than 9 years, though there is little evidence to determine efficacy in children of this age group (RELA)…
For people with tics who have access to CBIT, clinicians should prescribe CBIT as an initial treatment option relative to other psychosocial/behavioral interventions (Level B)....
People with tics receiving clonidine are probably more likely than those receiving placebo to have reduced tic severity, and people with tics receiving guanfacine are possibly more likely than those receiving placebo to have reduced tic severity, with the majority of trials conducted in children (EVID)…
Haloperidol, risperidone, aripiprazole, and tiapride are probably more likely than placebo to reduce tic severity (EVID), and pimozide, ziprasidone, and metoclopramide are possibly more likely than placebo to reduce tic severity (EVID). There is insufficient evidence to determine the relative efficacy of these drugs (EVID). Relative to placebo, the evidence demonstrates a higher risk of drug-induced movement disorders with haloperidol, pimozide, and risperidone (EVID), a higher risk of weight gain with risperidone and aripiprazole (EVID), a higher risk of somnolence with risperidone, aripiprazole, and tiapride (EVID), a higher risk of QT prolongation with pimozide (EVID), and a higher risk of elevated prolactin with haloperidol, pimozide, and metoclopramide (EVID). Systematic reviews of trials and cohort studies demonstrate a higher risk of drug-induced movement disorders (including tardive dyskinesia, drug-induced parkinsonism, akathisia, acute dystonia, and tardive dystonia), weight gain, adverse metabolic side effects, prolactin increase, and QT prolongation with both first- and second-generation antipsychotics across psychiatric and neurologic conditions (RELA).18,19 The long-term use of metoclopramide is associated with tardive dyskinesia, resulting in a black box warning from the US Food and Drug Administration...
Botulinum toxin injections with onabotulinumtoxinA are probably more likely than placebo to reduce tic severity in adolescents and adults (EVID). Premonitory urges may also be improved by botulinum toxin injections (RELA).24 Relative to placebo, onabotulinumtoxinA is associated with higher rates of weakness (EVID). Hypophonia is a common side effect of botulinum toxin injections in the laryngeal muscles for vocal tics (RELA). The effects of botulinum toxin injections last 12–16 weeks, after which treatment needs to be repeated (PRIN)...
Topiramate is possibly more likely than placebo to reduce tic severity (EVID). In patients with mild but troublesome tics who are not obtaining a satisfactory response or experience adverse effects from other treatments, topiramate may be a useful alternative...
Some patients with TS use cannabis as a self-medication for tics and comorbidities (RELA).29 There is limited evidence that δ-9-tetrahydrocannabinol (THC), dronabinol, is possibly more likely than placebo to reduce tic severity in adults with TS (EVID). There is insufficient evidence to determine whether the efficacy of nabiximols, nabilone, and cannabidiol (CBD), as well as different strains of medicinal cannabis—standardized for different levels of THC and CBD—is similar to THC.
The American Academy of Neurology (AAN) has published 49 new recommendations in a new guideline for treating tics in patients with Tourette syndrome and other chronic tic disorders.
To produce the guideline, the Guideline Development, Dissemination, and Implementation Subcommittee of the AAN assessed all high-quality randomized controlled trials that evaluated the efficacy of treatments for tics and the risks associated with their use. With this analysis, the Subcommittee made recommendations for when clinicians and patients should pursue treatment for tics and how clinicians and patients should choose between evidence-based treatment options.
Among the recommendations for the treatment of tics in individuals with Tourette syndrome or other chronic tic disorders are:
Pimozide is probably more effective than placebo in reducing tic severity,
Haloperidol is more effective than placebo in reducing tic severity, and
There is insufficient evidence to determine the efficacy of haloperidol compared with pimozide in reducing tic severity.
“There was high confidence that several interventions are more effective than placebo in reducing tic severity, including the Comprehensive Behavioural Intervention for Tics, haloperidol, risperidone, aripiprazole, tiapraide, clonidine, and guanfacine,” the committee wrote.
“There was moderate confidence that pimozide, ziprasidone, metoclopramide, topiramate, botulinum toxin injections, tetrahydrocannibinol and deep brain stimulation of the globus pallidus were more effective than placebo in reducing tic severity. Evidence of harm associated with various treatments were also demonstrated,” the committee wrote.
There were 49 recommendations in all, ranging from counseling recommendations, psychoeducation for teachers and peers, and assessment for comorbidities.
“The treatment of tics in individuals with [Tourette syndrome] and other chronic tic disorders must be individualized and based on collaborative decisions between patients, caregivers, and clinicians. Many children and adults with tic disorders have psychiatric comorbidities, and clinicians must endeavor to establish treatment priorities with their patients,” the committee concluded.
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