Risperidone in the treatment of Tourette syndrome: a retrospective case note study

Pharmacotherapies to tics: a systematic review

The efficacy of all pharmacotherapies for patients suffering from tics were unclear. Literatures were searched from Medline, Embase, The Cochrane Library, and four Chinese databases. The primary efficacy outcome scale was defined as the Yale Global Tic Severity Scale (YGTSS). Overall estimates of pooled weighted mean difference (WMD) with 95% confidence interval (CI) were calculated for each outcome measure. A total of 53 trials were included. Meta-analysis suggested that alpha-2 adrenergic agonist agents and atypical antipsychotic agents were effective in improving tics, which included the maximum number of trials. Typical antipsychotic agents were associated with severer side-effects than alpha-2 adrenergic agonist agents. Besides, Traditional Chinese Medicine showed positive effects in YGTSS (NingDong Granule: WMD=-7.100, 95% CI, -10.430- -3.770; 5-Ling Granule: WMD=-11.300, 95% CI, -14.208- -8.392), while glutamate modulators (D-serine, N-Acetylcysteine and riluzole) might not be working. In summary, alpha-2 adrenergic agonist agents were associated with the optimal weigh between efficacy and safety. However, the significant factor of limited trials and sample sizes discounted these findings. Further better studies are necessary to ascertain them.

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.

A personal 35 year perspective on Gilles de la Tourette syndrome: assessment, investigations, and management

After having examined the definition, clinical phenomenology, comorbidity, psychopathology, and phenotypes in the first paper of this Series, here I discuss the assessment, including neuropsychology, and the effects of Gilles de la Tourette syndrome with studies showing that the quality of life of patients with Tourette's syndrome is reduced and that there is a substantial burden on the family. In this paper, I review my local and collaborative studies investigating causal factors (including genetic vulnerability, prenatal and perinatal difficulties, and neuro-immunological factors). I also present my studies on neuro-imaging, electro-encephalograms, and other special investigations, which are helpful in their own right or to exclude other conditions. Finally, I also review our studies on treatment including medications, transcranial magnetic stimulation, biofeedback, target-specific botulinum toxin injections, biofeedback and, in severe refractory adults, psychosurgery and deep brain stimulation. This Review summarises and highlights selected main findings from my clinic (initially The National Hospital for Neurology and Neurosurgery Queen Square and University College London, UK, and, subsequently, at St George's Hospital, London, UK), and several collaborations since 1980. As in Part 1 of this Series, I address the main controversies in the fields and the research of other groups, and I make suggestions for future research.

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.

Treatment strategies for tics in Tourette syndrome

TOURETTE SYNDROME (TS) IS A CHRONIC NEURODEVELOPMENTAL DISORDER CHARACTERIZED BY TICS: repetitive, involuntary movements and vocalizations. These symptoms can have a significant impact on patients' daily functioning across many domains. Tics tend to be most severe in child and adolescent sufferers, so their presence has the potential to impact a period of life that is both critical for learning and is often associated with the experience of greater social tension and self-consciousness than adulthood. Furthermore, control over tics that lead to physical impairment or self-injurious behaviour is of vital importance in maintaining health and quality of life. There are numerous complicating factors in the prescription of treatment for tics, due to both the side effects associated with alleviating agents and patient characteristics, such as age and comorbid conditions. This review summarizes literature pertaining to the efficacy and safety of both traditionally prescribed and more modern medications. We also discuss the merits of behavioural and surgical techniques and highlight newer emerging treatments. Although treatment response is to some extent variable, there are a number of agents that are clearly useful as first-line treatments for TS. Other interventions may be of most benefit to patients exhibiting refractory tics or more specific symptom profiles.

Emerging drugs in Tourette syndrome

Proper education of the patient is the first step in the treatment of Tourette syndrome (TS). Before deciding how to treat the patient, it is important to decide whether to treat the TS-related symptoms. Counselling and behavioural modification may be sufficient for those with mild symptoms. Medications, however, may be considered when symptoms begin to interfere with peer relationships, social interactions, academic or job performance, or with activities of daily living. Therapy must be individualised and the most troublesome symptoms should be targeted first. Antidopaminergic agents are clearly the most effective drugs in the treatment of tics. Although haloperidol and pimozide are the only drugs currently approved by the FDA for the treatment of TS, other dopamine receptor-blocking drugs and tetrabenazine, a dopamine depleting drug, as well as botulinum toxin injections, have been used to treat tics associated with TS. Carefully designed, comparative, longitudinal trials assessing the efficacy and adverse-effect profiles of these drugs, including tardive dyskinesia, are lacking. Selective serotonin reuptake inhibitors are recommended for the treatment of obsessive-compulsive behaviour: a common comorbidity. Psychostimulants, such as methylphenidate, are the treatment of choice for attention deficit hyperactivity disorder. Even though these drugs may transiently increase tics, this does not necessarily constitute a definite contraindication to the use of these drugs in patients with TS. Here, existing and emerging medical treatments in patients with tics and comorbid behavioural disorders associated with TS are reviewed.

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

The aim of this 6-week, open-label design study was to determine the short-term effectiveness and safety of risperidone as an alternative for traditional antipsychotic drugs in the treatment of chronic tic disorder or Tourette's Disorder in young children and adolescents. The subjects were 15 young children and adolescents (the ratio of male:female subjects was 13:2 and their mean age was 10 +/- 2.4 years). Seven subjects were diagnosed with Tourette's Disorder and 8 subjects with chronic tic disorder, and all subjects were administered risperidone without hospitalization. Of the 15 subjects, 1 subject had a comorbid disorder (obsessive compulsive disorder), but no subject had a previous history of psychiatric hospitalization. Ten of the 15 subjects were administered risperidone for the first time, and 5 of the 15 subjects had been previously treated with traditional drugs (haloperidol or pimozide). Clinical responses were measured at baseline and after 1, 3, and 6 weeks of drug treatment by using the Korean version of the Yale Global Tic Severity Scale and the Global Assessment of Functioning Scale. Side effects were carefully monitored using adverse event evaluation charts. The mean dosage of risperidone was 0.53 +/- 0.13 mg on the 1st week, 0.90 +/- 0.28 mg on the 3rd week, and 1.23 +/- 0.37 mg on the 6th week. Comparison between periods according to the Korean version of the Yale Global Tic Severity Scale showed significant differences (t = 4.920; df = 14; p < 0.01) during the 1st- to 3rd-week period. After 6 weeks of administration, the tic severity scale showed a 36% reduction in the overall tic symptom scores and 13 of the 15 subjects showed significant improvement, 1 subject showed no difference in symptoms, and, for 1 subject, the symptoms worsened. Also, the mean Global Assessment of Functioning Scale score was 66.8 +/- 10.8 at baseline and improved to a mean of 73.1 +/- 10.1 after 6 weeks of treatment. Regarding side effects, only 1 case reported sedation, but drug administration was continued because the degree was mild. The results of this study show that, risperidone, a potent combined serotonin (5-HT2) and dopamine (D2) receptor antagonist, is both effective and safe for the treatment for Tourette's Disorder and chronic tic disorder in children and adolescents.

Therapie der Tic-Störungen

Zusammenfassung: Hintergrund: In den letzen zehn Jahren wurde in zahlreichen Studien über die Therapie der Tic-Störungen berichtet. Die Einführung neuartiger Neuroleptika sowie die immer weiter entwickelten Techniken der Verhaltenstherapie geben den von einer Tic-Störung betroffenen Kindern und Jugendlichen neue Hoffnung. Fragestellung: Um die neuen Standards in der Therapie kennen zu lernen, ist es notwendig, sich kritisch mit der Qualität dieser Studien zu befassen. Methode: Eine kritische Übersicht der evidenzbasierten Literatur und praktischer Erfahrungen. Ergebnisse: Weltweit existiert hinsichtlich der Pharmakotherapie der fundierteste klinische Kenntnisstand zu Clonidin und (aus der Gruppe der neuen Antipsychotika) zu Risperidon, während in Europa die Benzamide seit Jahrzehnten sehr erfolgreich angewendet werden. Zu verhaltenstherapeutischen Verfahren finden sich zunehmend empirische und hilfreiche Daten. Schlussfolgerung: Risperidon könnte das Medikament der ersten Wahl bei der Behandlung der Tic-Störungen werden. Verhaltenstherapeutische Verfahren scheinen immer häufiger in multimodalen Therapiekonzepten angewendet zu werden.

Pharmacological management of tics in patients with TS

This article reviews the evidence published in the English language literature concerning the pharmacological treatment of tics in patients with Tourette Syndrome. The focus is on the efficacy and safety of the current treatments. A clinical approach to pharmacological management of Tourette Syndrome patients is outlined.

A controlled study of psychopathology and associated symptoms in Tourette syndrome

BACKGROUND

Gilles de la Tourette syndrome (GTS) is a neurobehavioural disorder of genetic origin, although the precise inheritance pattern is as yet undetermined. This study was designed to describe symptomatology in GTS subjects. It describes the severity of depressive, anxiety and obsessional symptoms when compared to other samples of GTS patients, matched controls and normative data.

METHODS

87 consecutive GTS clinic referrals (children and adults) were interviewed in 1996 and 1997 using the National Hospital Interview Schedule, the Yale Global Tourette Severity Score, the Diagnostic Confidence Index, Beck Depression Inventory (BDI), Spielberger State-Trait anxiety Index (STAI) and Leyton Obsessional Inventory (LOI). 52 healthy controls were interviewed using the BDI, STAI and LOI. The clinical status of the subjects was described and ratings of psychopathology were compared with the control group and with normative data. Data were compared with previous data from similar clinic samples.

RESULTS

In this controlled study, GTS subjects scored highly on ratings of depression, state anxiety and obsessionality when compared with controls and with normative data. Scores in the subjects group were similar to previous findings in clinic samples of people with GTS.

CONCLUSIONS

People with GTS who attend clinics have a variety of psychological symptoms that are significantly more severe than controls. Accessory symptoms (e.g. coprophenomena, echophenomena) were also very common in the subject group. Psychological symptoms may occur as part of the disease, a reaction to disability or as a result of ascertainment bias.

Gilles de la Tourette's syndrome

Tourette's syndrome (TS) is a childhood onset neurological disorder characterized by motor and vocal tics. It may be associated with a number of co-morbidities including attention deficit hyperactivity disorder, obsessive compulsive symptomatology, and behaviour disorders. Prevalence of TS is higher than previously thought, and may be present in up to 2% of the population. Tourette's syndrome has a significant genetic component. Inheritance may involve several mechanisms including autosomal dominant, bilinear, or polygenic mechanisms. Pathophysiology is still unknown, although is thought to involve striatocortical circuits. Treatment begins with modification of the work and home environment. For more severe cases, medications such as tetrabenazine and neuroleptics may be helpful. Treatment of co-morbidities needs to be considered, as these may result in moredisability than the tics themselves.

Risperidone in the treatment of tourette syndrome: a double-blind, placebo-controlled trial

A double-blind, placebo-controlled trial was performed to determine the efficacy and tolerability of 8 weeks of treatment with risperidone in the management of 48 adolescent and adult patients with Tourette syndrome. Twenty-four patients were randomly assigned to treatment with risperidone in doses of 0.5 to 6.0 mg/day, and 24 were assigned to placebo. The dosage of medication was increased in fixed increments during the first week of double-blind treatment and thereafter in a flexible dose regimen according to clinical response. Risperidone, at a median dose of 2.5 mg/day (range, 1 to 6 mg/day), was found to be significantly ( p < 0.05) superior to placebo on the Global Severity Rating of the Tourette Syndrome Severity Scale. The proportion of patients who improved by at least one point on this seven-point scale was 60.8% in the risperidone group and 26.1% in the placebo group. Treatment with risperidone was accompanied by an improvement in global functioning in patients with average to above-average impairment at baseline as measured by the Global Assessment of Functioning scale. With respect to extrapyramidal symptom scores measured on the Extrapyramidal Symptom Rating Scale, hypokinesia and tremor increased in the risperidone group, but the effect on tremor was largely confined to subjects with higher baseline tremor scores. There were no significant differences in dystonic reactions, dyskinetic movements, subjective parkinsonism, or akathisia. Risperidone did not increase obsessive-compulsive symptoms. Fatigue and somnolence were the most common adverse events associated with risperidone.

Tics and its disorders

Tourette syndrome (TS) is familial neuropsychiatric disorder that is characterized by motor and phonic tics that begin in childhood. Once thought of as a rare and debilitating disorder, in the last decade new scientific knowledge suggests that TS and related tic disorders are more common and less debilitating for the majority of individuals. Evidence points toward a spectrum of TS symptomatology that extends beyond the tics disorder to probably include obsessive-compulsive disorder, attention deficit hyperactivity disorder, and mood disorders. Tourette syndrome and its differential diagnosis are discussed in this article with a focus on new developments in classification, etiology, epidemiology, genetics, pathophysiology, and clinical management.

Gilles de la Tourette syndrome: symptomatic treatment based on evidence

The treatment of the Gilles de la Tourette syndrome has evolved from case reports, clinical experience and more recently blinded trials usually in small numbers of patients. We have reviewed the evidence available to clinicians. The oldest and still most widely prescribed drug, haloperidol, should now not be considered the first-line agent in children as other agents have superior adverse effects profiles. Symptomatic treatment should be targeted to the specific additional psychopathologies seen in the syndrome. For the treatment of tics, sulpiride, tiapride, possibly pimozide and in some cases clonidine may be considered first-line agents. Although a body of data supports pimozide, caution has to be exercised in relation to possible cardiac effects. Antidepressants and stimulants have an important place in the management of depression, obsessionality and attention deficit hyperactivity disorder. The latter also responds to clonidine making it a rational first choice where ADHD coexists with GTS. There are a multitude of other drugs advocated in the literature in addition to reports of neurosurgery and the novel use of immune modulation. Therapeutic trials for GTS are challenging. However, further data from blinded trials are required before many of these treatments can be considered to be mainstream treatment options.

The treatment of tics

Tics are the essential component of a variety of disorders, notably Tourette syndrome. Because the mere presence of tics does not require therapeutic intervention, criteria are essential for determining a functional disability. Suggested tic-suppressing treatments have been extremely diverse, including hydrotherapy, behavioral treatments, pharmacotherapy, botulinum toxin, immunomodulatory therapy, and surgery. This manuscript reviews each of these approaches with emphasis on more recent pharmacologic trials.

Tic disorders: new developments in Tourette syndrome and related disorders

The constellation of motor and vocal tics and certain of the other neuropsychiatric symptoms seen in Tourette syndrome are thought to have an organic basis, although the nature of the neurobiological lesion is uncertain. The syndrome is usually familial but the presumed genetic substrate has not been identified. A number of models currently under debate include a proposed autoimmune contribution.