Effectiveness and safety of risperidone for children and adolescents with chronic tic or tourette disorders in Korea

Therapeutic drug monitoring in children and adolescents with schizophrenia and other psychotic disorders using risperidone

Risperidone is commonly used to treat different psychiatric disorders worldwide. Knowledge on dose–concentration relationships of risperidone treatment in children and adolescents with schizophrenia or other psychotic disorders is, however, scarce and no age-specific therapeutic ranges have been established yet. Multicenter data of a therapeutic drug monitoring service were analyzed to evaluate the relationship between risperidone dose and serum concentration of the active moiety (risperidone (RIS) plus its main metabolite 9-hydroxyrisperidone (9-OH-RIS)) in children and adolescents with psychotic disorders. Patient characteristics, doses, serum concentrations and therapeutic outcomes were assessed by standardized measures. The study also aimed to evaluate whether the therapeutic reference range for adults (20–60 ng/ml) is applicable for minors. In the 64 patients (aged 11–18 years) included, a positive correlation between daily dose and the active moiety (RIS_am) concentration was found (r_s = 0.49, p = 0.001) with variation in dose explaining 24% (r_s² = 0.240) of the variability in serum concentrations. While the RIS_am concentration showed no difference, RIS as well 9-OH-RIS concentrations and the parent to metabolite ratio varied significantly in patients with co-medication of a CYP2D6 inhibitor. Patients with extrapyramidal symptoms (EPS) had on average higher RISam concentrations than patients without (p = 0.05). Considering EPS, the upper threshold of the therapeutic range of RIS_am was determined to be 33 ng/ml. A rough estimation method also indicated a possibly decreased lower limit of the preliminary therapeutic range in minors compared to adults. These preliminary data may contribute to the definition of a therapeutic window in children and adolescents with schizophrenic disorders treated with risperidone. TDM is recommended in this vulnerable population to prevent concentration-related adverse drug reactions.

Trichotillomania is more related to Tourette disorder than to obsessive-compulsive disorder

OBJECTIVE

Trichotillomania (TTM) is characterized by the pulling out of one's hair. TTM was classified as an impulse control disorder in DSM-IV, but is now classified in the obsessive-compulsive related disorders section of DSM-5. Classification for TTM remains an open question, especially considering its impact on treatment of the disorder. In this review, we questioned the relation of TTM to tic disorder and obsessive-compulsive disorder (OCD).

METHOD

We reviewed relevant MEDLINE-indexed articles on clinical, neuropsychological, neurobiological, and therapeutic aspects of trichotillomania, OCD, and tic disorders.

RESULTS

Our review found a closer relationship between TTM and tic disorder from neurobiological (especially imaging) and therapeutic standpoints.

CONCLUSION

We sought to challenge the DSM-5 classification of TTM and to compare TTM with both OCD and tic disorder. Some discrepancies between TTM and tic disorders notwithstanding, several arguments are in favor of a closer relationship between these two disorders than between TTM and OCD, especially when considering implications for therapy. This consideration is essential for patients.

Effects of orthopedic treatment using temporomandibular joint balancing appliance (TBA) at improving the symptoms of tic/Tourette syndrome: case report

Tic disorder is characterized as sudden, non-rhythmic, involuntary and repetitive movement or vocalization, and its onset occurs mainly in childhood or adolescence. The development of medication has been limited because of a lack of understanding of tic mechanisms, and behavioral treatment is recommended as a first-line treatment. In this case report, we observed three cases in which tic disorder or Tourette syndrome was treated with intraoral orthopedic treatment (FCST) combined with acupuncture and an herbal formula and was assessed using the Yale Global Tic Severity Scale (YGTSS), a visual analog scale (VAS) and video analysis. The symptoms were reduced in 30 days and remained at the reduced level until 240 or 300 days after the first day of treatment. Most of the symptoms were disappeared after 240-300 days. Therefore, we could conclude that orthopedic treatment combined with Korean medicine may be applied for tic disorder in accordance with the efficacy and low adverse event rate, and we also suggests a large-scale clinical report to provide concrete evidence before the global application.

Update on the Pharmacological Treatment of Tics with Dopamine-Modulating Agents

More than 40 years of research and clinical practice have proven the effectiveness of dopamine receptor antagonists in the pharmacological treatment of tics. A blockade of the striatal dopamine-D2 receptors is mainly responsible for their tic-reducing effect. A broad spectrum of dopamine-modulating agents, such as typical and atypical antipsychotics, but also dopamine receptor agonists are used with an immanent discord between experts about which of them should be considered as first choice. The present Review outlines the state of the art on pharmacological treatment of tics with dopamine-modulating agents by giving an systematic overview of studies on their effectiveness and a critical discussion of their specific adverse effects. It is considered as an update of a previous review of our research group published in 2013. The Review closes with a description of the current resulting treatment recommendations including the results of a first published revised survey on European expert's prescription preferences. Based on the enormously growing evidence on its effectiveness and safety, aripiprazole currently seems to be the most promising agent in the pharmacological treatment of tics. Furthermore, benzamides (especially tiapride), which are commonly used in Europe, have proven their excellent effectiveness-tolerability profile over decades in clinical practice and are therefore also highly recommended for the treatment of tics. Nevertheless, pharmacological treatment of tics remains an indiviual choice depending on each patient's own specific needs.

Aripiprazole for the treatment of tic disorders in children: a systematic review and meta-analysis

BACKGROUND

Tic disorders (TDs) are common neuropsychiatric disorders in children. Typical antipsychotics, such as haloperidol and pimozide have been prescribed to control tic symptoms as first-line agents. However, adverse effects have led to the use of newer atypical antipsychotics. Aripiprazole is one of alternatives. The aim of this study was to evaluate the efficacy and safety of aripiprazole for children with TDs.

METHODS

Randomized controlled trials (RCTs), quasi-RCTs and control studies evaluating aripiprazole for children with tic disorders were identified from PubMed, Embase, Cochrane library, Cochrane Central, four Chinese database and relevant reference lists. Quality assessment referred to the Cochrane Handbook for Systematic Reviews of Interventions.

RESULTS

Twelve studies involving 935 participants were included. The general quality of included studies was poor. Only one study used placebo as a control and others used positive drug controls. Participants were aged between 4 and 18 years. The period of treatment ranged from 8 to 12 weeks. Seven studies (N = 600 patients) used the YGTSS scale as the outcome measurement, and there was no significant difference in reduction of the total YGTSS score between the aripiprazole and positive control groups (MD = -0.48, 95 % CI [-6.22, 5.26], P = 0.87, I(2) = 87 %). Meta-analysis of four of the studies (N = 285 patients) that compared aripiprazole with haloperidol showed that there was no significant difference in reduction of the total YGTSS score (MD = 2.50, 95 % CI [-6.93, 11.92], P = 0.60, I(2) = 88 %). Meta-analysis of two studies (N = 255 patients) that compared aripiprazole with tiapride showed that there was no significant difference in reduction of the total YGTSS score (MD = -3.15, 95 % CI [-11.38, 5.09], P = 0.45, I(2) = 86 %). Adverse events (AEs) were reported in 11 studies. Drowsiness (5.1 %-58.1 %), increased appetite (3.2 %-25.8 %), nausea (2 %-18.8 %) and headache (2 %-16.1 %) were common AEs.

CONCLUSION

In conclusion, aripiprazole appears to be a promising therapy for children with TDs. Further well-conducted RCTs are required to confirm this issue.

The role of atypical antipsychotics for treatment of Tourette's syndrome: an overview

Tourette's syndrome (TS) is a neuropsychiatric disorder of childhood onset characterized by multiple motor and phonic tics that fluctuate over time. Tic symptoms often improve by late adolescence, but some children and adults with TS may experience significant tic-related morbidity, including social and family problems, academic difficulties, and pain. When more conservative interventions are not successful, and when certain psychiatric co-morbidities further complicate the clinical profile, treating TS with an atypical antipsychotic medication may be a reasonable second-tier approach. However, the evidence supporting efficacy and safety of the atypical antipsychotics for treatment of tics is still very limited. The objective of this paper is to provide an updated overview of the role of atypical antipsychotics for treatment of TS, with evidence-based guidance on their use. Evidence for efficacy of different typical and atypical antipsychotics for treatment of tics was examined by conducting a systematic, keyword-related search of 'atypical antipsychotics' and 'Tourette's syndrome' in PubMed (National Library of Medicine, Washington, DC, USA). Four recent treatment consensus publications were also reviewed. This review focused on literature published from 2000 to 2013 and on available randomized controlled trials in TS. Evidence supporting the use of atypical antipsychotics for treatment of TS is limited. There are few randomized medication treatment trials in TS (i.e. risperidone, aripiprazole, ziprasidone), which employed varying methodologies, thereby restricting meaningful comparisons among studies. Future collaborations among clinical sites with TS expertise employing high-quality study design may better elucidate the role of atypical antipsychotics for treatment of TS.

Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome

Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.

Update on the role of antipsychotics in the treatment of Tourette syndrome

Tourette syndrome (TS) is a neuropsychiatric disorder with typical onset in childhood and characterized by chronic occurrence of motor and vocal tics. The disorder can lead to serious impairments of both quality of life and psychosocial functioning, particularly for those individuals displaying complex tics. In such patients, drug treatment is recommended. The pathophysiology of TS is thought to involve a dysfunction of basal ganglia-related circuits and hyperactive dopaminergic innervations. Congruently, dopamine receptor antagonism of neuroleptics appears to be the most efficacious approach for pharmacological intervention. To assess the efficacy of the different neuroleptics available, a systematic, keyword-related search in PubMed (National Library of Medicine, Washington, DC) was undertaken. Much information on the use of antipsychotics in the treatment of TS is based on older data. Our objective was to give an update and therefore we focused on papers published in the last decade (between 2001 and 2011). Accordingly, the present review aims to summarize the current and evidence-based knowledge on the risk-benefit ratio of both first and second generation neuroleptics in TS.

European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment

To develop a European guideline on pharmacologic treatment of Tourette syndrome (TS) the available literature was thoroughly screened and extensively discussed by a working group of the European Society for the Study of Tourette syndrome (ESSTS). Although there are many more studies on pharmacotherapy of TS than on behavioral treatment options, only a limited number of studies meets rigorous quality criteria. Therefore, we have devised a two-stage approach. First, we present the highest level of evidence by reporting the findings of existing Cochrane reviews in this field. Subsequently, we provide the first comprehensive overview of all reports on pharmacological treatment options for TS through a MEDLINE, PubMed, and EMBASE search for all studies that document the effect of pharmacological treatment of TS and other tic disorders between 1970 and November 2010. We present a summary of the current consensus on pharmacological treatment options for TS in Europe to guide the clinician in daily practice. This summary is, however, rather a status quo of a clinically helpful but merely low evidence guideline, mainly driven by expert experience and opinion, since rigorous experimental studies are scarce.

Open-label study comparing the efficacy and tolerability of aripiprazole and haloperidol in the treatment of pediatric tic disorders

Due to its unique pharmacodynamic properties of dopamine partial agonist activity, and its association with few and mild side effects, aripiprazole is a candidate atypical antipsychotic for patients with tic disorders. This open-label study compared the efficacy and tolerability of aripiprazole with haloperidol, a typical antipsychotic widely used to treat patients with tic disorders. Forty-eight children and adolescents with tic disorders were recruited from the outpatient clinic at South Korea and treated with aripiprazole (initial dose, 5.0 mg/d; maximum dose 20 mg/d) or haloperidol (initial dose, 0.75 mg/d; maximum dose, 4.5 mg/d) for 8 weeks. Treatment efficacy was measured using the yale global tic severity scale (YGTSS), and tolerability was measured using the extrapyramidal symptom rating scale (ESRS) and an adverse effects checklist. Total tic scores as measured by the YGTSS decreased over time in both groups (p < 0.001) without any significant differences between groups. ESRS scores were significantly higher in the haloperidol group during the 4 weeks after commencement of medication (p < 0.05). These results indicate that aripiprazole may be a promising drug in the treatment of children and adolescents with tic disorders. Further controlled studies are needed to determine the efficacy and tolerability of aripiprazole in these patients.

Current issues in the treatment of OC-spectrum conditions

Obsessive-compulsive (OC)-spectrum conditions consist of neurological-motoric conditions, impulse-control disorders, and disorders associated with bodily preoccupation. This article is a review of some understudied OC-spectrum conditions, with particular focus on phenomenology and overlap with obsessive-compulsive disorder, etiology, treatment outcome, treatment refractory issues, and new developments in treatment research. The focus will be on representative disorders from each related area, namely, Tourette's syndrome, trichotillomania, skin-picking, and body dysmorphic disorder. Similarities among the disorders and areas in need of more research are discussed.

[Aripiprazole - a medical treatment alternative for Tourette Syndrome in childhood and adolescence]

OBJECTIVE

We report a case-series of seven patients with a medical history of at least two years of tic disorder treated with the partial dopamine agonist aripiprazole to illustrate its efficacy as a treatment alternative for motor and vocal tics in children and adolescents.

METHOD

A case series of five patients with Tourette Syndrome (TS) and two with chronic motor tic disorder (age range 8; 7-18; 1 year), the majority of whom had been refractory to treatment with other neuroleptics or had ceased treatment due to intolerable side effects, were treated for eight weeks with aripiprazole. Before and after treatment, parents rated the severity of motor and vocal tic symptoms on the Yale Tourette Syndrome Checklist.

RESULTS

Within eight weeks mean motor tic symptoms decreased by 66% and mean vocal tic symptoms decreased by 26%. Mean effective dosage was 14.3 mg/day (min. 5 mg, max. 30 mg). Symptoms of comorbid ADHD or Obsessive Compulsive Disorder were not significantly influenced. During medication only mild side effects were observed, e.g., abdominal pain, fatigue and increased emotional sensitivity. No patient dropped out of treatment due to side effects.

CONCLUSIONS

Aripiprazole may be an effective pharmacologic treatment alternative for individuals with chronic motor tic disorder and TS. It induces quick, significant and sustained effects with few generally mild and transient side effects, if anything. Its effectiveness, especially relative to comorbidities, should be verified in double-blind, placebo-controlled studies.

Aripiprazole in the pharmacotherapy of Gilles de la Tourette syndrome in adult patients

Despite the ongoing development of neuroleptics, typical or first-generation neuroleptics are still considered as the first choice in the treatment of Gilles de la Tourette syndrome (GTS). In many European countries, tiapride is the first line of treatment favoured in most cases, while risperidone, pimozide and haloperidol are listed as second choice. Unfortunately, antipsychotics often show tachyphylactic effects in the treatment of GTS so that a switch to another neuroleptic agent becomes inevitable. Thus it is important to ensure a wide selection of different drugs is available. Another promising candidate in the treatment of tics may be aripiprazole, a D(2)-receptor partial agonist. We present the retrospective analysis of 10 clinical cases of adult patients from the tic clinics in Aachen (Germany) and Zurich (Switzerland) who were treated with aripiprazole. Tics and disturbances were assessed using the Yale Global Tic Severity Scale (YGTSS). All YGTSS-subscores, with the exception of the complexity of vocal tics, improved significantly. The data includes three cases with long-term intake for at least 18 months. During this period, no tachyphylactic effect was visible. A double-blind trial against placebo or other neuroleptics is advisable to verify the efficacy of aripiprazole in the pharmacotherapy of GTS.

[Risperidone use in child and adolescent psychiatric patients]

In a plural and multidisciplinary process of care, it would be fruitful to ally complementary, pharmacologic and psychodynamic approaches. We have done a review of the literature on the effectiveness and the cautions for prescription of risperidone, a second generation antipsychotic drug. Risperidone has proved helpful in treating children and adolescents with autism spectrum, conduct and bipolar disorders, Tourette's syndrome, and schizophrenia. The principal side effects are sedation, weight gain, and metabolic disturbances. Extrapyramidal symptoms, QTc prolongation, and hyperprolactemia with clinical signs are infrequent and not clinically significant. The benefit/risk is clearly in favor of the prescription when it is accompanied with the precautions and with the adequate monitoring.

Tourette's syndrome and role of tetrabenazine: review and personal experience

Gilles de la Tourette's syndrome (Tourette's syndrome; TS) is an inherited tic disorder commonly associated with other neurobehavioural conditions such as attention-deficit hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD). While the clinical presentation of TS and other features of this disorder have been well characterized, the genetic and neurobiological basis of the disease remains incompletely elucidated. The suggestion of a central role of dopamine in the aetiology of TS has been made on the basis of experimental studies, evidence from neuroimaging studies and the therapeutic response patients with TS have to agents that antagonize or interfere with putative dopaminergic pathways. Tetrabenazine is such an agent; it depletes presynaptic dopamine and serotonin stores and blocks postsynaptic dopamine receptors. In clinical studies, tetrabenazine has been found to be effective in a wide range of hyperkinetic movement disorders, including small numbers (<50) of patients with TS in some studies. Results of a retrospective chart review enrolling only patients with TS (n = 77; mean age approximately 15 years) showed that 2 years' treatment with tetrabenazine resulted in an improvement in functioning and TS-related symptoms in over 80% of patients, findings that suggest that treatment with tetrabenazine may have long-term benefits. The authors' experience with 120 heavily co-medicated patients with TS confirms these findings. Long-term (mean 19 months) tetrabenazine treatment resulted in a Clinical Global Impressions of Change scale rating of 'improved' in 76% of patients. Such findings are promising and suggest that tetrabenazine may be suitable as add-on therapy in patients for whom additional suppression of tics is required.

Randomized double-blind multicentre placebo-controlled clinical trial of the clonidine adhesive patch for the treatment of tic disorders

OBJECTIVE

The aim of the present study was to evaluate the therapeutic effectiveness and safety of the clonidine adhesive patch in treating tic disorders.

METHOD

A total of 437 patients, who met Chinese Classification of Mental Disorders-third edition diagnostic criteria for transient tic disorder (5%), chronic motor or vocal tic disorder (40%) or Tourette disorder (55%), aged 6-18 years, were divided randomly into an active treatment group and a clinical control group. Participants in the active treatment group were treated with a clonidine adhesive patch and participants in the clinical control group with a placebo adhesive patch for 4 weeks. The dosage of the clonidine adhesive patch was 1.0mg, 1.5mg or 2.0mg per week, depending on each participant's bodyweight. Participants whose Yale Global Tic Severity Scale (YGTSS) score decreased <30% and Clinical Global Impression score was > or =4 by the end of week 3 were withdrawn from the trial.

RESULTS

After 4 weeks of treatment the active treatment group participants' YGTSS score was significantly lower than that of the clinical control group (F=4.63, p=0.03). Further, the active treatment group had a significantly better therapeutic response than the clinical control group (chi(2)=9.15, p=0.003). The response rate in the active treatment group was 68.85% compared to 46.85% in the clinical control group (chi(2)=16.98, p=0.0001). The rate of adverse events was low (active treatment group, 3.08%; clinical control group, 7.21%) and did not differ between the two groups.

CONCLUSIONS

The clonidine adhesive patch is effective and safe for tic disorders.

Novel uses for risperidone: focus on depressive, anxiety and behavioral disorders

Risperidone has been shown to be a safe and effective atypical antipsychotic agent. It was initially approved for the treatment of schizophrenia, and now, in many countries, is used to treat other conditions, including bipolar disorder, dementia and behavior problems in a range of age groups. Yet, frequent off-label use by clinicians to treat other mood and anxiety disorders and behavioral disorders is common and requires an examination of the risks and benefits in such populations. A review of the literature provides varying levels of evidence supporting its use in a range of depressive and anxiety disorders, and in special populations, including children and the elderly. Most reports are based on short-term studies and include its use both as monotherapy and as an augmenting agent to other psychotropics, and in a range of doses. Further randomized controlled trials are needed to confirm the efficacy and tolerability of risperidone, both short- and long-term, in many of these conditions. The published evidence is summarized, with recommendations and suggestions for its use.

Symptom dimensions in obsessive-compulsive disorder: implications for the DSM-V

In the absence of definitive etiological markers of vulnerability or a unitary profile of pathophysiology for obsessive-compulsive disorder (OCD), obsessive-compulsive (OC) symptom dimensions seem to offer a fruitful point of orientation. The complex clinical presentation of OCD can be summarized using a few consistent and temporally stable symptom dimensions. These can be understood as a spectrum of potentially overlapping features that are likely to be continuous with "normal" worries and extend beyond the traditional nosological boundaries of OCD. Although the understanding of the dimensional structure of obsessive-compulsive symptoms (OCS) is still imperfect, this quantitative approach to phenotypic traits has the potential to advance our understanding of OCD and may aid in the identification of more robust endophenotypes. Preliminary data suggest that these dimensional phenotypes may be useful in studies of the natural history, genetics, neurobiology, and treatment outcome of OCD. A dimensional approach is not mutually exclusive of other methods to parse the larger spectrum of disorders related to OCD. Thus far, age-of-onset of OCS and the individual's "tic-related" status seem to be particularly useful categorical distinctions. Finally, existing assessment methods are inadequate and new dimensional scales are needed to take full advantage of a dimensional approach in clinical and population-based studies.

Clinical effectiveness of quetiapine in children and adolescents with Tourette's syndrome : a retrospective case-note survey

BACKGROUND AND OBJECTIVE

Tourette's syndrome is a relatively common biological genetic disorder with a broad spectrum of neurobehavioural manifestations. Unfortunately, treatment of the condition is often unsatisfactory and all available drugs are associated with potential adverse effects. We therefore aimed to investigate the efficacy of quetiapine, a newer atypical antipsychotic, in the treatment of children and adolescents with Tourette's syndrome.

METHODS

This was a retrospective study carried out in outpatient clinics. Twelve patients aged 8-18 years with Tourette's syndrome (diagnosed according to Diagnostic and Statistical Manual IV criteria) who were receiving quetiapine therapy and had no diagnosis of epilepsy, major depression or psychotic disorder, were included in the study. The main outcome measure was the Yale Global Tic Severity Scale (YGTSS) score.

RESULTS

The initial dose of quetiapine was 25 mg/day, but the mean dose was increased to 114.6 +/- 51.6 mg/day and 175.0 +/- 116.8 mg/day at the fourth and eighth weeks of treatment, respectively. The YGTSS score, which was 21.6 +/- 4.0 at baseline, showed significant decreases at 4 and 8 weeks (reducing to 7.5 +/- 7.4 and 5.6 +/- 8.1, respectively; p < 0.003). Routine laboratory parameters and serum prolactin level were all normal and did not change throughout treatment. Mild but significant increases in both bodyweight and body mass index at 4 and 8 weeks compared with baseline were observed.

CONCLUSION

Other than causing mild weight gain, quetiapine appears to be an effective, safe and well tolerated drug in children and adolescents with Tourette's syndrome.