New treatments for tics?

Tourette syndrome (TS) and related tic disorders are common. A recent community-based epidemiologic study indicated that about 3% of school-aged children show evidence of TS.1 For most, the tics may go unnoticed, are not disabling, and require no medical attention or consideration of treatment. For those individuals in whom tics interfere with normal daily functioning, a variety of tic-suppressing medications are available.

Alpha adrenergic agonists are considered first-line pharmacotherapy for tics. A recent multicenter controlled clinical trial of the Tourette’s Syndrome Study Group (TACT Trial) confirmed that clonidine is effective.2 Because sedation is a common dose-limiting side effect of clonidine, many clinicians prefer the alternative alpha adrenergic agonist guanfacine. It has the advantage of once per day dosing and causes less drowsiness,3 although its efficacy has not been fully established in controlled trials. If an alpha adrenergic agonist is not tolerated or inadequate, second-line therapy usually involves a so-called atypical antipsychotic, such as risperidone or olanzapine.4-6⇓⇓ Atypical agents are preferred over classic neuroleptic antipsychotics owing to a better side effect profile, particularly for extrapyramidal effects such as acute dystonia and drug-induced parkinsonism. Traditional neuroleptic antipsychotic medications that block D2 dopamine receptors, such as haloperidol, pimozide, and fluphenazine, remain the most predictable tic-suppressing drugs available, but have fallen into third-line status owing to poor tolerability. These drugs are frequently associated with sedation, weight gain, depression, irritability, phobias, and other adverse effects …