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
Abstract
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.
No comments:
Post a Comment