Pediatric Tourette Syndrome Medication

Updated: Mar 25, 2015
  • Author: Jason S Hawley, MD; Chief Editor: Eduardo Dunayevich, MD  more...
  • Print
Medication

Medication Summary

Alpha2-adrenergic agonists and D2 dopamine receptor blocking medications are used primarily for tic suppression. The alpha2-adrenergic agonists may be effective at treating underlying ADHD symptoms, although CNS stimulants and atypical neuroleptics can be used concurrently. Selective serotonin reuptake inhibitors (SSRIs) are predominantly used to treat obsessive-compulsive disorder (OCD) symptoms in Tourette syndrome (TS). Aripiprazole, an atypical antipsychotic, has been approved by the FDA for pediatric TS.

Next:

Neuroleptic drugs

Class Summary

Dopamine-receptor antagonists are the most predictably effective tic-suppressing agents.

Haloperidol (Haldol)

Haloperidol and droperidol are of the butyrophenone class and are noted for high potency and low potential for causing orthostasis. A high potential for extrapyramidal symptoms/dystonia exists.

Pimozide (Orap)

Pimozide is a dopamine-receptor antagonist that alters effects of dopamine in the CNS. It possesses anticholinergic and alpha-adrenergic blocking activity. Because of its long half-life (55 h), a single daily dose may be feasible.

Fluphenazine (Prolixin)

Fluphenazine blocks postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the brain. This agent exhibits strong alpha-adrenergic and anticholinergic effects and may depress the reticular activating system.

Trifluoperazine (Stelazine)

Fluphenazine blocks postsynaptic mesolimbic dopaminergic D1 and D2 receptors in the brain. This agent exhibits strong alpha-adrenergic and anticholinergic effects and may depress the reticular activating system.

Previous
Next:

Atypical neuroleptic drugs

Class Summary

These agents are selective dopamine receptor D2 and serotonin (5-HT2) antagonists.

Aripiprazole (Abilify)

Aripiprazole is indicated for Tourette syndrome in children aged 6-18 years. It elicits partial agonistic effect at dopamine D2 and serotonin type 1 (5-HT1A) receptors (thought to help control vocal tics).

Risperidone (Risperdal)

Risperidone is a selective monoaminergic antagonist with high affinity for serotonergic 5-HT2 and dopaminergic D2 receptors. It is postulated to antagonize dopamine receptors in the limbic system only. It exhibits selective serotonin blockade in the mesocortical tract. Dopamine levels and transmission increase.

Olanzapine (Zyprexa)

Olanzapine is considered a second-line agent for tic suppression. Of the atypical neuroleptics, risperidone has been more thoroughly studied than olanzapine.

Ziprasidone (Geodon)

This agent is an atypical antipsychotic approved by the FDA in 2001. It may cause less weight gain than olanzapine.

Previous
Next:

Alpha2-adrenergic agonists

Class Summary

Alpha2-adrenergic agonists are first-line agents for pharmacotherapy of tics

Clonidine (Catapres, Duraclon, Nexiclon, Kapvay)

Clonidine stimulates alpha2-adrenoreceptors in the brain stem, activating an inhibitory neuron, which in turn results in reduced sympathetic outflow. These effects result in a decrease in vasomotor tone and heart rate. Clonidine is a first-line agent for tic suppression and treatment of ADHD in TS.

Guanfacine (Tenex, Intuniv)

Guanfacine is considered a first-line agent for treatment of tics. It has a longer half-life than clonidine and can be less sedating.

Previous
Next:

Benzodiazepines

Class Summary

These agents inhibit calcium ions from entering slow channels, select voltage-sensitive areas, or smooth muscle.

Clonazepam (Klonopin)

Clonazepam suppresses muscle contractions by facilitating inhibitory gamma aminobutyric acid (GABA) neurotransmission and other inhibitory transmitters.

Previous
Next:

Dopamine agonists

Class Summary

Dopamine agonists are hypothesized to reduce dopamine receptor supersensitivity, which is one proposed theory of the underlying pathophysiology of TS. Evidence for the effectiveness of dopamine agonists in TS is encouraging but limited; further research needs to be done for this class of medications in TS.

Pergolide, a dopamine agonist, was withdrawn from the US market March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. Pergolide should not be stopped abruptly. Health care professionals should assess patients’ need for dopamine agonist (DA) therapy and consider alternative treatment. If continued treatment with a DA is needed, another DA should be substituted for pergolide. For more information, see FDA MedWatch Product Safety Alert and Medscape Alerts: Pergolide Withdrawn From US Market.

Ropininirole (Requip)

Ropinirole is considered a third-line agent for treatment of TS. Lower doses than those used in Parkinson disease have been shown to be effective.

This agent is a nonergot dopamine agonist that has high relative in vitro specificity and full intrinsic activity at D2 subfamily of dopamine receptors, binding with higher affinity to D3 than to D2 or D4 receptor subtypes. It has moderate affinity for opioid receptors. Metabolites have negligible affinity for dopamine D1, 5HT-1, 5HT-2, benzodiazepine, GABA, muscarinic, alpha1-, alpha2- and beta-adrenoreceptors.

Discontinue ropinirole gradually over a 7-day period. Decrease frequency of administration from tid to bid for 4 days. For the remaining 3 days, decrease frequency to once daily prior to complete withdrawal of ropinirole.

Pergolide (Permax)

Pergolide has been withdrawn from the US market. A mixed ergot derivative dopamine agonist, it was proven effective for tic suppression

Previous
Next:

Neuromuscular blocker agents

Class Summary

These agents inhibit muscle contractions.

Botulinum toxin (BOTOX®)

A neurotoxin produced from fermentation of Clostridium botulinum type A, this agent exerts neuromuscular blockade by binding to receptor sites on presynaptic motor nerve terminals and inhibiting calcium-dependent release of acetylcholine from vesicles situated within nerve endings. Partial chemical denervation of muscle results, which diminishes muscle activity in area of injection.

Previous