Clinical Pharmacology of Comorbid Attention Deficit Hyperactivity Disorder in Tourette Syndrome

European clinical guidelines for Tourette syndrome and other tic disorders-version 2.0. Part III: pharmacological treatment

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients' self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient's needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician's preferences, experience, and local regulatory requirements.

Potential Role of Dexamphetamine in the Treatment of Non-alcoholic Fatty Liver Disease: Hopes and Pitfalls

Non-alcoholic fatty liver disease (NAFLD) is one of most frequent causes of chronic liver disease. Global prevalence of NAFLD and nonalcoholic steatohepatitis (NASH) with advanced fibrosis is increasing day by day. Patients with NAFLD are more susceptible to encounter cardiovascular morbidity and mortality. Apart from lifestyle changes and dietary modifications, no effective pharmacotherapy is available to prevent the progression of NAFLD to NASH and advanced stages of hepatic fibrosis and cirrhosis. Dexamphetamine is the d-isomer of amphetamine, which acts by inhibiting monoamine reuptake and direct stimulation of dopamine and noradrenaline release. Presently, dexamphetamine is indicated for the treatment of attention deficit hyperactivity disorder and narcolepsy, but since its use was found to be associated with weight loss, it is also now used as an off-label drug for the treatment of obesity. Direct or indirect evidence is present in the form case reports, case series and from effects of related drugs to support the potential role of dexamphetamine in NAFLD. There is an urgent need to initiate preclinical and clinical studies involving robust methodology and adequate sample sizes to explore the potential of dexamphetamine in patients with NAFLD. In this review, we will discuss the therapeutic potential of dexamphetamine for the treatment of NAFLD.

Potential Role of Dexamphetamine in the Treatment of Non-alcoholic Fatty Liver Disease: Hopes and Pitfalls

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Tourette's disorder in children and adolescents

Tourette's disorder (TD) is one of the five American Psychiatric Association's 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifications of tic disorders. Eponymously linked with the noted 19th century French physician, Gilles de la Tourette [1857-1904], this disorder is identified in 0.3% to 0.7% of the population. It is characterized as a familial neuropsychiatric condition with multiple motor tics and vocal tics (one or more) present for more than 1 year with varying severity. The underlying pathophysiology involves dysfunctional activity of the basal ganglia and circuitry of the frontal cortex as well as dorsolateral striatum deficits. Contributory factors include genetic features interacting with milieu influences. A number of comorbid disorders are seen including obsessive-compulsive disorder (OCD) and attention-deficit/hyperactivity disorder (ADHD). Concepts of management are considered including behavioral therapy and pharmacologic approaches with alpha-adrenoceptor agonists, atypical antipsychotics (AAs), haloperidol, pimozide and others. Other management includes botulinum injections and deep brain stimulation in adults.

A selective review of glutamate pharmacological therapy in obsessive-compulsive and related disorders

Glutamate, an excitatory central nervous system neurotransmitter, is emerging as a potential alternative pharmacological treatment when compared to gamma-aminobutyric acid (GABA)-, dopamine-, and serotonin-modulating treatments for neuropsychiatric conditions. The pathophysiology, animal models, and clinical trials of glutamate modulation are explored in disorders with underlying inhibitory deficits (cognitive, motor, behavioral) including obsessive–compulsive disorder, attention deficit hyperactivity disorder, Tourette syndrome, trichotillomania, excoriation disorder, and nail biting. Obsessive–compulsive disorder, attention deficit hyperactivity disorder, and grooming disorders (trichotillomania and excoriation disorder) have emerging positive data, although only scarce controlled trials are available. The evidence is less supportive for the use of glutamate modulators in Tourette syndrome. Glutamate-modulating agents show promise in the treatment of disorders of inhibition.

Managing attention-deficit/hyperactivity disorder in children and adolescents

Attention-deficit/hyperactivity disorder (ADHD) is the most frequently diagnosed neurodevelopmental disorder; 6.4 million children and adolescents have been diagnosed with ADHD as of 2011. However, only 3.5 million children and adolescents are taking medication for ADHD. Adolescents with ADHD are much less willing to pursue or adhere to medication or psychosocial therapy, often because of their perceptions of side effects or perceived value of treatment, which places them at greater risk for difficulties at school, work, and home environments. Providing adolescents with increased autonomy through patient-centered approaches can increase their involvement and ability to manage their ADHD symptoms and treatment.