No está claro cuán grande es el papel de los antibióticos https://antibioticos-wiki.es en las relaciones competitivas entre los microorganismos en condiciones naturales. Zelman Waxman creía que este papel era mínimo, los antibióticos no se forman sino en culturas limpias en entornos ricos. Posteriormente, sin embargo, se descubrió que en muchos productos, la actividad de síntesis de antibióticos aumenta en presencia de otros tipos o productos específicos de su metabolismo.
Depts.washington.edu
This publication is intended to provide information about Tourette Syndrome, its management and medications currently in use. Families are advised to consult a physician concerning all treatments and medications. Tourette Syndrome (TS) or Tourette’s disorder (DSM
expertise and the time to do the evaluation and be able
IV-TR) is a childhood onset, brain-based disorder
to start and monitor medication treatment. The evalu-
characterized by persistent motor and vocal tics that
ation should at minimum identify problems related to
last for more than one year. Tics are brief, meaningless
tics and any co-occurring conditions. Other important
movements or sounds, but can be more complex and
components of a good evaluation include the patient’s
appear purposeful. In addition, many people with TS
general health, family history of any medical and psy-
have other problems that might include one or more
chiatric problems, treatment history including which
of the following: difficulties with attention, learning,
medications the person is taking currently or might
compulsive behavior, anxiety, irritability, depression,
have taken in the past. A thorough evaluation is a criti-
impulsivity and aggression. The challenge of living
cal first step for making good medication choices.
with tics and co-occurring problems can often lead to poor functioning in school, in the work place and dif-
The next step is a discussion with the clinician
ficulty with social adjustment. For many, medication
about the results of the evaluation, the plan for treat-
treatment for tics and these co-occurring problems can
ment and available treatment options. This discus-
be very helpful in reducing symptoms and improving
sion should focus on the problems identified and the
reasons for deciding on a particular treatment plan. Although people with tics tend to pursue treatment when symptoms are significant, it is important not to
be in too much of a hurry. Some tic exacerbations may resolve in time and therefore may not require treatment
Even though medications can be helpful in reducing tic
with medication (e.g. tic increases due to excitement
severity, most people with TS will not require prescrip-
during holidays or vacations). It is worth the time it
tion medications for their tics. The need for medication
takes to make a good decision about whether or not to
depends on the severity of tic symptoms, the presence
of co-occurring problems and the person’s overall func-tional capacity. For example, those with very frequent
The final step is the actual treatment trial — a
tics, but who are not distressed by them, may not want
process of finding the best dose with the fewest side
or require medication. On the other hand, some with
effects. Most clinicians begin medication with a low
less severe symptoms may experience impairment in
dose and increase the dose over time in order to reduce
social, school or work functioning and elect to pursue
tic severity while keeping medication side effects to a
medication treatment. Ultimately, the decision about
minimum. It is extremely important when beginning
whether or not to start a medication should take these
medication to report both the benefits and side effects
realities into account. Even though not everyone may
to the clinician so that the best and safest dose of medi-
need medication for their tics, it is important for every-
one to know what the treatment options are.
Although everyone would like to take the lowest
possible effective dose of medication, sometimes higher
General Principles of Medication Treatment
doses may be necessary and should not, in principle, be avoided or cause undue concern. Finding the best dose of medication for a child can be more complicated than
Prior to starting medication it is important to find a
for adults. Although children often use lower doses
qualified clinician (e.g. physicians, nurse practitioners
than adults, parents should not automatically assume
and psychologists) for an evaluation. Although many
that children always require low doses of medication.
clinicians can provide evaluation and treatment ser-
Actually, children sometimes require doses similar to
vices, it is important to identify a clinician who has the
those of adults or even higher. It is advisable to work
with clinicians experienced in treating children and
problems first may be helpful in ways that the child
who are aware of such differences and take them into
and family hadn’t initially considered. By addressing
account when prescribing medication. With the right
these problems first, functioning at school and at home
clinician a medication trial can be accomplished -- even
might improve and make it less likely that the tics will
Because most medications do not show benefit
Those coping with both tics and another co-oc-
immediately, the pacing of dose adjustments is also
curring problem may require treatment for both condi-
important. Taking too long to increase the dose of
tions. Sometimes addressing two (or more problems)
a medication may unnecessarily prolong suffering;
may require a treatment plan that includes two (or
increasing doses too quickly may inadvertently over-
more) medications. While it is always simplest to use
shoot the effective dose and increase the risk of side
one medication, taking two medications to treat two or
effects. Once an optimal medication dose is identified,
more problems is routine practice, and should not cause
ongoing monitoring is required to assess for continuing
undue concern. That said, while careful monitoring
benefit, side effects and adherence to the medication
and good communication are important when on a sin-
gle medication, these precautions are critically impor-tant when medication combinations are prescribed.
After a period of successful treatment, the clini-
cian may suggest reducing the dose of medication in
Some people with TS lead very difficult lives. At
order to identify the lowest dose that is necessary to
times their difficulties are caused by their symptoms,
maintain good tic control. Because tic symptoms rou-
sometimes by how others treat them, and sometimes
tinely wax and wane and improve over time, periodical-
their problems are due to the decisions and choices
ly reducing the dose of medication is an important part
they make for themselves. Although this brochure
of tic treatment. Almost all tic suppressing medications
focuses on medication treatment, it is very important
should be reduced slowly to find the lowest effective
to note that not all the problems a person with TS
dose. A slow reduction in medication is particularly
faces can be resolved by taking medication or reducing
important for those who have been on tic suppressing
tic symptoms. Actually, psychological treatments may
medications for an extended period of time. The same
be the most important and valuable first treatment step
goes for discontinuing medication; the dose should be
reduced slowly and then stopped, and never stopped abruptly. Stopping tic suppressing medications abrupt- ly can actually cause tics to worsen in a way that would
Where Can One Get Good Information about
not otherwise occur with a more gradual reduction in dose. Some patients actually develop transient motor
movements called “withdrawal dyskinesia” from dis-continuing medication too quickly. Your clinician will
For information about specific medications, there are
prescribe a safe step-by-step program for decreasing
quite a few helpful resources. Perhaps the easiest way to
dosage until the medication is discontinued completely.
access information about medications is from reputable sources on the Internet. A drug manufacturer’s website
Problems that co-occur with TS may also respond
provides specific product information that has been
to medication. At the end of the evaluation, it is not
reviewed and approved by the U.S. Food and Drug
uncommon for people with TS to become more aware
Administration. This is the same information that is
of just how these co-occurring problems have been
in the Physicians’ Desk Reference (PDR) and is the
impacting their lives. If co-occurring problems are
basis of the information provided by pharmacists with
more impairing or distressing than the tics, clinicians
every prescription. A medication’s product informa-
may suggest that the co-occurring problems be treated
tion is usually of very high quality, but not always easy
first rather than treating the tics. For example, a child
to read and understand. MedlinePlus website http://
with mild to moderate tics may have more significant
medlineplus.gov is a public service provided by the
problems with attention and concentration at school,
U.S. National Library of Medicine and the National
or anxiety and fears at home. Treating these other
Institutes of Health. This website provides basic infor-
suppressing will refer to their use for other conditions
mation about prescription and over-the-counter medi-
without mentioning their usefulness in treating TS.
cations as well as some herbs and supplements. The
The information below describes basic information
information is presented in a straightforward, easy-to-
about how these medications are commonly prescribed
read manner and is prepared by the American Society
of Health-System Pharmacists based on information from the U.S. Pharmacopea and MedMaster® drug
Antipsychotics
information database. Because most medications used for tic suppression are marketed for other medical con-
Antipsychotics are the most effective group of medi-
ditions, there is usually limited information about how
cations for reducing tic severity. They are classified
these medications work in TS. Therefore, textbooks on
as major tranquilizers or antipsychotic medications
TS and review articles about TS in the medical litera-
because they are generally prescribed for hallucina-
ture can be very helpful in clarifying how medications
tions, delusions and problems with thinking and orga-
nization in people with psychosis. These medications have also been categorized as antiemetics because they
Although other websites may be helpful as well, it
can be effective in reducing severe nausea and vomiting.
is important to “consider the source” and not be unduly
There are a number of medications considered to be
influenced by websites that are less than reputable. It
part of the antipsychotic class, and most of these have
is important to remember that there are some people
and organizations that have very strong opinions about using medications to address medical and behavioral
Antipsychotic medications are thought to be
problems. Some of these websites provide information
helpful for TS symptoms because of their ability to
that is not necessarily based on scientific evidence and
decrease dopamine function in the brain. Dopamine is
the information posted may even employ “scare tactics”
a neurotransmitter--a brain chemical--which is involved
to influence people about the safety and efficacy of spe-
in nerve cells communicating with each other. Some
antipsychotics have a lot of specific power to reduce dopamine functioning and some have less power. Antipsychotics also differ in their impact on other
brain neurotransmitters (e.g. serotonin, norepineph-rine, acetylcholine). The effect of a specific antipsy-
The medications used for reducing tic severity or treat-
chotic on dopamine and other neurotransmitters will
ing co-occurring conditions come from different drug
impact the medication’s possible benefits as well as its
classes. Within each class there are a number of medi-
cation options a clinician and patient might choose. That is why, individuals with TS and their families
Antipsychotic medications with proven efficacy for
should discuss with their clinicians the specific symp-
reducing tic severity include the typical antipsychot-
toms to be targeted for medication treatment and the
ics haloperidol (Haldol®), pimozide (Orap®), and the
specific medication to be used. The following section is
atypical antipsychotic risperidone (Risperdal®). Others
organized by class of medication and then within each
antipsychotics may also be helpful [e.g. fluphenazine
class are the specific medication options.
(Prolixin®)] even if they have not been specifically stud-ied in TS. In general, antipsychotics with the greatest
Tic Suppressing Medications
dopamine blocking activity are the most effective for reducing tics. However, the decision about which medi-
There is no medication that has been discovered or
cation a person should take depends on which medica-
developed specifically for the purpose of reducing tic
tion may benefit the specific patient best. Clinicians
severity. Rather, medications developed to treat other
may suggest using a medication other than one with a
medical and psychiatric conditions have been later
long track record because balancing the benefit and side
found to be helpful in reducing tics. As a result, most
effects may fit the individual better than medications
of the published information about medications for tic
Reducing dopamine function is helpful for reduc-
In addition to the common side effects of antipsy-
ing tic severity, but reducing dopamine function may
chotics described above, it is important to know about
also result in unwanted effects on motor control such
two very uncommon, but significant complications of
as stiffness, slowed movements and unwanted muscle
antipsychotic treatment--tardive dyskinesia and antip-
contractions (i.e dystonic reactions, tremor and rest-
sychotic malignant syndrome. Discussing these compli-
lessness).These side effects are common enough that
cations of antipsychotic treatment in this brochure does
people should be aware of them and understand the
not mean that they are likely to occur; rather they are
best way to manage them. They are all reversible either
described here to put the risk of these side effects into
by reducing the dosage, or in some cases by discontinu-
perspective and allay concerns of individuals who may
ing the medication. Moreover, some of these motor
side effects can be controlled by taking anticholinergic medications such as benztropine (Cogentin®), diphen-
Tardive dyskinesia is a motor side effect of chronic
hydramine (Benadryl®) and trihexyphenidyl (Artane®).
antipsychotic treatment which is rare in individuals
Anticholinergic medications may be started with a
with TS, but more common in individuals treated
antipsychotic to prevent the development of unwanted
chronically with antipsychotics for psychosis. Tardive
motor side effects, or given after motor side effects
dyskinesia tends to be a more continuous movement
develop to reduce discomfort. Similarly, because antip-
problem than tics which tend to be brief and episodic.
sychotics are tranquilizers and reduce agitation for
Features of tardive symptoms can include the inability
people with psychosis, they may be too tranquilizing
to hold the tongue or mouth still (i.e. chronic worm-
for people with TS, resulting in sedation or reduced
like or chewing movements). Writhing movements of
the arms, legs, and trunk may also occur. When the hands are affected, the person may appear to be play-
In general, the dose of antipsychotic used to treat
ing an invisible guitar or piano. Tardive dyskinesia
psychosis is considerably higher than doses used for tic
may emerge during extended treatment with antipsy-
suppression. A dose of antipsychotic for tic suppression
chotics or may occur when the antipsychotic dosage is
may range from 5-30% of the daily dose required for
reduced after long term treatment. There is no specific
psychosis. There are always exceptions to such general
treatment for tardive dyskinesia. When symptoms
statements, but usually, high doses of antipsychotics for
are identified, medication discontinuation is recom-
tic suppression are not more helpful than lower doses,
mended unless the medication is absolutely critical to
cause more side effects and therefore are not recom-
maintain functioning. Because it can be difficult to dis-
tinguish some complex tics from symptoms of tardive dyskinesia, a movement disorder specialist should be
To improve the treatment for psychosis and to
consulted when it is suspected that a person with TS
decrease the risk for motor side effects, atypical antip-
has developed tardive dyskinesia after treatment with
sychotics were developed. Atypical antipsychotics have
relatively less impact on dopamine and more impact on other neurotransmitter systems. Because of the lesser
Antipsychotic malignant syndrome (NMS) is a
effects on dopamine, atypical antipsychotics may be a
very rare and potentially serious complication of antip-
better choice for people with TS who are sensitive to
sychotic treatment. Although the cause is unknown,
motor side effects caused by the typical antipsychot-
the symptoms of NMS are consistent with nearly
ics. In addition, atypical antipsychotics may impact
complete blockage of dopamine function that leads to
other neurotransmitter systems as well, resulting in
severe muscle rigidity, fever, seizures, muscle break-
a broader range of benefits (e.g. improved mood or
down and kidney failure. When identified early, NMS
impulse control) for people with TS. Although atypical
can be effectively treated. If NMS symptoms are not
antipsychotics may have less risk for motor side effects,
recognized and not addressed appropriately, they can
some appear to increase appetite and cause weight
result in death. It must be emphasized that NMS is
gain. Recently there has been increasing concern about
extremely rare in individuals with TS and that clini-
antipsychotic-induced weight gain being associated
cians are specifically trained to observe for the signs
with the development of metabolic problems including
of NMS. Therefore, concerns about NMS should not
non-insulin dependent diabetes (i.e. type II diabetes)
result in rejecting a trial of antipsychotics for tic sup-
Alpha Adrenergic Agonists Medications Not Wel -Studied for Reducing Tic Severity
Another class of medications commonly used for
tic suppression are the Alpha Adrenergic Agonists —
Many other medications have been prescribed to
clonidine and guanfacine (Catapres® and Tenex® respec-
individuals with TS to reduce tic severity. However,
tively). These medications are marketed to control high
these medications are less well established and there-
blood pressure, but have been prescribed for a number
fore less commonly used. One problem with evaluating
of other conditions, including drug withdrawal syn-
whether a medication is effective in reducing tics is the
dromes and tics. Exactly how alpha adrenergic agonists
fact that tics wax and wane over time. As most people
reduce tic severity is not known, but it may be related
tend to seek treatment when their symptoms are at
to decreased central nervous system arousal.
their worst (people don’t go to the clinician when all is well), it is not uncommon for people to experience
Dosages of alpha agonists for tic symptoms are
some decrease in tic symptoms right after visiting their
usually lower than those used in the treatment of high
clinician--even when no treatment has been prescribed.
blood pressure. Because alpha agonists are short acting,
Therefore, a person beginning medication may falsely
for optimal tic control multiple doses throughout the
attribute the reduction in tics to the effects of the
day (2-4 doses) may be required. Although some people
medication, rather than to the natural course of the
with TS may have a fairly dramatic response to alpha
disorder. For this reason most clinicians are skeptical
agonists, most experience more modest benefit than
of reports about a single person doing very well on a
what is usually observed when taking antipsychotic
newer or less established treatment. Understandably,
medications. On the other hand, the side effect profile
clinicians are more confident about treatments that
of the alpha agonists is milder than that of the anti-
have proved effective in well-designed scientific studies.
psychotics. The most common side effect is sedation
which can occur even at fairly low doses. Some chil-
Clonazepam (Klonopin®) is a minor tranquilizer
dren on alpha adrenergic medications have exhibited
used in the treatment of anxiety, seizures and bipolar
disorder and has been studied and found to be helpful for tic suppression. Reducing anxiety in people with
As described below, alpha agonists can also be
TS may in and of itself reduce tic severity.
helpful in treating Attention Deficit Hyperactivity Disorder (ADHD). The combination of modest benefit
Early studies of nicotine in the form of a skin
for tics and ADHD plus a better side effect profile
patch or chewing gum and nicotine blocking medica-
than antipsychotics is why some clinicians choose alpha
tions such as mecamylamine (Inversine®) were both
agonists first when prescribing medication to treat chil-
found to be to be helpful in reducing tics. However,
subsequent definitive studies have not borne out the initial enthusiasm for these treatments. Baclofen (a
Both clonidine and guanfacine come in a patch
muscle relaxant), tizanidine (used to treat muscle
form. When attached to the skin, the patch releases the
spasticity), and topiramate (used for seizures) may be
medication into the blood stream more gradually than
helpful for tics, but further, more definitive evaluation
pills thus providing more convenient dosing and consis-
tent medication effects. The patch option decreases the need for pill taking multiple times each day, and may have fewer side effects than the pill form. However, some people develop a skin rash at the site of the patch prompting discontinuation.
Table 1. Medications used in the Treatment of Tics
Typical Antipsychotics Medication Usual Starting Usual Treatment Comments Dose Dose Haldol®
for tics. Often not used as the first medication for tic suppression due to side effects.
effects make pimozide a second choice for tic suppression.
Similar to haloperidol, but some believe
Prolixin®
it has a milder side effect profile. A good first choice typical antipsychotic for tic suppression. Tiapridex Tiapridal
(Belgium, France, Spain, Holland, Switzerland)sulpiride
Dogmatil Sulpital Sulparex
(UK, Europe) Atypical Antipsychotics risperidone
Probably the best atypical antipsychotic
Risperdal®
for tic suppression. May have less risk for motor side effects than haloperidol and fluphenazine. May also benefit impulse control and aggression. Weight gain can be a significant problem in some patients. Invega® Geodon®
for the development of weight gain. Unclear how helpful it is for tic suppres-sion. Lowest available dose is 20 mg. Studies of ziprasidone had other dose preparations available that are not avail-able currently. Zyprexa®
weight gain is greater than risperidone. Seroquel®
studied in TS and unclear on how effec-tive it is for tics. Dosing is not estab-lished. Abilify®
nism of action. Studies are currently underway. Appears promising as a tic-surpressing medication but dosage is not yet established.
Recently available in the United States. Xenazine® Nitoman® Adrenergic Agonists clonidine Catapres®
tic suppresion. Not consistently as effec-tive as antipsychotics for tic suppression. Also helpful for ADHD.
Same as clonidine tablets, localized skin
Catapres® patch Tenex CR®
choice fo tic suppression in children with ADHD. Benzodiazepines clonazepam
Some potential for developing tolerance.
Klonopin®
Slow tapering may be required for dis-continuation. Stimulants for TS Plus Attention Deficit
attributing such worsening to having begun to take a
Hyperactivity Disorder
medication. Although it appears that stimulants can be used safely in people with tics and ADHD, the product
The most commonly used medications for Attention
labeling of methyphenidate and amphetamine products
Deficit Hyperactivity Disorder (ADHD) are central
discourages using stimulants in people with tics or
nervous system stimulants which contain the chemical
people with a family history of tics. Although scientific
compounds methylphenidate (e.g. Ritalin®, Concerta®,
studies do not necessarily support this concern, it is
Metadate® and Methylin®), dextroamphetamine
highly unlikely that the labeling will change. As you
(Dexedrine® and Dextrostat®) and mixed amphetamine
can imagine it is difficult for a pharmaceutical company
salts (Adderall®). Stimulants have proved effective for
to remove warnings from their labeling as it may make
ADHD symptoms in children with and without TS.
them more vulnerable to lawsuits. For children with
Common side effects of stimulants include appetite
tics and ADHD whose clinician has recommended a
suppression and difficulty falling asleep. One of the
stimulant, it is important to know that the evidence
greatest drawbacks of stimulant medications is their
base for safety and the product information for stimu-
short duration of action. To have maximum benefit,
children with ADHD may have to take medication
multiple times each day including at school. To address
Lastly, recent media reports and U.S. Food and
this drawback the pharmaceutical industry has devel-
Drug Administration hearings have alerted all to the
oped new longer acting preparations to extend the
risk of stimulants in children with known heart defects
duration of benefit thus making stimulants more useful
and also to the worsening of symptoms of other psy-
for people over the course of a day.
chiatric disorders. It is important before beginning to take stimulants that the prescribing clinician be aware
In the late 1970’s and 1980’s there were numer-
of the patient’s personal and family history of cardiac
ous published reports that children taking stimulants
developed new onset tics or experienced worsening tics. One confounding factor regarding stimulants “causing”
Non-Stimulant Medication for ADHD
new or worsening tics is the fact that ADHD symp-
Treatment
toms often emerge before the development of tics. So if stimulants are begun for ADHD and then tics appear,
Because of past concerns about the association of
it is difficult to know whether the tics are “caused”
stimulants with the emergence of new tics or the wors-
by the stimulant, or whether the onset of tics would
ening of current tics, clinicians have sought alternative
have occurred anyway as part of the natural course of
medications to treat ADHD symptoms. Perhaps the
the tic disorder. Whether stimulants actually cause
most common alternatives are clonidine and guanfa-
tic worsening can be determined in a research study
cine. Both have proved effective in reducing both tic
by comparing the rates of tic worsening in subjects on
severity and ADHD symptoms. Common side effects
medication vs. placebo. In such studies, tic worsening
of these two medications include sedation and irrita-
has not occurred more commonly in those on stimu-
bility. Another medication with an FDA indication
lant medication compared to placebo. Interestingly,
for ADHD is atomoxetine (Strattera®). Atomoxetine
the Tourette Syndrome Study Group’s study compar-
is a norepinephrine reuptake inhibitor that has dem-
ing methylphenidate to clonidine and placebo showed
onstrated efficacy for ADHD in children with tics.
similar rates of tic worsening (approximately 20-25%)
Common side effects of atomoxetine include sedation,
in each group. The lack of a difference between meth-
gastrointestinal upset and irritability. In the past, tri-
ylphenidate and placebo suggests there is no risk for
cyclic antidepressants were found useful for ADHD
tic worsening that can be specifically attributed to tak-
in children with and without tics. A number of case
ing the stimulant methylphenidate. It is important for
reports of sudden death in children taking desipramine
the clinician, parents and the child to pay attention to
in the early 1990’s has had a significant negative impact
how frequently tics worsen after starting medication
on the number of clinicians prescribing this medica-
treatment. All should be aware that tic worsening is
tion for ADHD. While there are theories about why
something that might occur during any treatment with
tricyclic antidepressant might have been a contributing
any medication, even placebo, and to be careful about
factor in these deaths there is no proven causal link.
Table 2. Medications used in the treatment of co-occurring ADHD and TS Medication Usual Starting Usual Treatment Comments Dose Dose Antidepressants imipramine
A tricyclic antidepressant less commonly used
Tofranil®
today due to poor tolerability and risk for
electrocardiogram changes especialy in chil-
dren. May have benefits for ADHD, anxiety
and depression. Helpful for sleep problems in
Shown to be effective in children with ADHD
Norpramin®
and TS, but risk for electrocardiogam changes
Pamelor®
A novel antidepressant with a unique mode
Wellbutrin®
of action. Effective in ADHD, but benefit is
Wellbutrin XR®
smaller than stimulants Risk for seizures if
Wellbutrin SR® Stimulant medications methylphenidate
Commonly used stimulant available in short
Ritalin®
and long-acting preparations. Short acting
Ritalin SR®
preparations may require midday and late
Ritalin LA®
afternoon dosing. Longer acting compunds
Methylin®
may require 1-2 doses per day depending on
Methylin ER®
the preparation. Common side effects include
Concerta®
decreased appetite, insomnia and irritability. Metadate® Metadate ER® Metadate CD® dexmethylphenidate Focalin® dextroamphetamine
Commonly used stimulant with both short and
Dexedrine® DexePatch®
methylphenidate in efficacy and side effects. Dextrostat® Dexedrine® spansules amphetamine salts
A combination of four different d-amphet-
Adderall®
amine and l-amphetamine compounds. Similar
Adderall XR®
to dextroamphetamine and methylphenidate in
lisdexamfetamine
Vyvanse ® Norepinephrine reuptake inhibitors atomoxetine
A unique medication for ADHD based on its
Strattera®
effects on norepinephrine. Dosing in chldren is
based on weight. Common side effects include
sedation, stomach upset, vomiting and irritabil-
ity. May require several weeks for dose adjust-
ment to maximize benefit and minimize side
SSRIs and other Antidepressants
for drug interaction are better for someone sensitive to side effects and are already on other medications.
A class of antidepressant medications found useful
While SSRIs are generally well tolerated some people
when treating Obsessive Compulsive Disorder (OCD),
early in the course of treatment may feel activated or
other anxiety disorders and depression are the Selective
agitated, have gastrointestinal side effects or headaches.
Serotonin Reuptake Inhibitors (SSRIs). Most of these
These side effects can be managed by reducing the
are approved for use or have demonstrated safety and
dose and in some cases, discontinuing the medication.
benefit in children and adults with OCD down to as
Clomipramine is a tricyclic antidepressant that is also
young as age 6 years. Unlike stimulant medications
useful in treating OCD in children and adults because
that work almost immediately, antidepressant medica-
tions often take from 2-4 weeks of treatment to begin to be effective. To maintain benefit over time requires
Although not common, antidepressants, including
that the person take the medicine consistently at an
the SSRIs, can also induce manic reactions (e.g. eupho-
effective dose. Extended treatment with antidepres-
ria, grandiosity, decreased need for sleep and increased
sants 9-12 months minimum may be necessary for
interest and involvement in high risk activities). This
ongoing control of symptoms. Too low a dose and/or
worrying complication may require management by
too short a duration of treatment are the primary rea-
a psychiatrist experienced in treating people with
sons for poor outcomes with antidepressants.
bipolar disorder. More recently the Food and Drug Administration has warned that about 2% of young
The various SSRIs differ both in their half-life
people treated with antidepressants may experience
(i.e. how long it takes for the body to reduce the blood
an emergence or worsening of suicidal thoughts and
level by half) as well as their potential for drug inter-
behaviors. Your clinician is the best person to help you
actions. Long half-life SSRIs take longer to leave the
understand whether the potential benefit of medication
body after discontinuation, but they are also more sta-
outweighs this small potential risk. Clinicians, patients
ble when doses are missed. Short half-life SSRIs clear
and their families need to know about all risks, includ-
from the body more quickly if side effects develop, but
ing the risk of not treating anxiety and depression,
may be less effective when doses are missed. Clinicians
and be vigilant early in the course of treatment for the
often weigh these factors when recommending an
unexpected emergence or worsening of depression or
SSRI. For example, short acting SSRIs with a low risk
Table 3. Antidepressants for OCD, Anxiety and Depression Medication Usual Usual Comments Starting Dose Treatment Dose Serotonin reuptake inhibitors fluoxetine
The SSRI with the longest half-life and highest
Prozac®
potential for interacting with other drugs. Only
SSRI approved by the FDA for use in children
The half-life of paroxetine gets longer with
repeated dosing. Similar to fluoxetine in benefits,
side effects and drug interactions. Paroxetine may
be more often associated with sedation, weight
gain and withdrawal reactions than other SSRIs.
A SSRI with a short half-life and fewer potential
Zoloft®
drug interations than fluoxetine. However, the
product labeling advises against combining sertra-
One of the first SSRIs with demonstrated effici-
cacy in childhood and adult OCD. A short acting
SSRI with a different drug interaction profile
than fluoxetine, paroxetine and sertraline.
A medium duration half-life with similar side
Celexa®
effect profile to the other SSRIs. Lower likeli-
hood for drug interactions than fluoxetine and
Citalopram consists of two mirror image com-
Lexapro®
pounds called isomers. Escitalopram is the
medicinally active form of the two compounds.
Escitalopram has a medium half-life and a side
effect profile similar to the other SSRIs.
A tricyclic antidepressant with serotonin enhanc-
Anafranil®
ing properties. Useful in OCD. It is not as selec-
tive for serotonin as the SSRIs and has more side
effects, but may be useful for those with OCD
who have trouble sleeping. Combining clomip-
ramine with some SSRIs may increase risk for
side effects and decrease its efficacy. Norepinephrine reuptake inhibitors venlafaxine
Has both serotonin and norepinephrine enhanc-
Effexor®
ing properties useful in severe depression. Side
Effexor XR®
effects similar to the SSRIs but may increase
blood pressure especially at higher doses.
Has both serotonin and norepinephrine effects.
Cymbalta®
New to the market and no information about use
Modern technology and high quality control in the
Tic symptoms range from mild to severe with most
generic pharmaceutical manufacturing industry guar-
people experiencing mild symptoms; many individu-
antee that generic medications are effective. However,
als never require medication treatment for their tics.
generic medications may not be exactly the same as
However, people with tics may have other prob-
their brand name counterparts. Some individuals
lems that can benefit from medication treatment.
switching to generics from brand name products or
Sometimes treating the co-occurring conditions is more
switching from one generic to another have reported
helpful than treating the tics. Lastly, not all problems
experiencing no problems. And yet, others have found
faced by people with TS require medications and may
the generics to be less effective than the brand name
actually be better addressed with psychological inter-
products. In general, it is recommended to be consis-
ventions. Before starting any treatment a good evalua-
tent when taking either the brand name medication
tion is key to maximizing the chance that a treatment
or generic. In other words, it is not advisable to switch
plan will be successful. The TS research community
back and forth between brand name medications
is working actively to discover new and better treat-
and generics or even among generics. Individuals are
ment programs. Until that time, the currently available
encouraged to discuss this issue carefully with their
medications can be helpful to many individuals with
In this brochure the author has made every
effort to provide the best available information about medications commonly used to reduce tic severity and treat conditions commonly co-occurring in Tourette
To meet the pharmacological treatment needs of adults
Syndrome. This information is not meant to be
and children with TS requires a very careful assess-
exhaustive and does not reflect the rapidly changing
ment, identification of the most impairing condition
nature of medical treatment for TS and co-occurring
— be it tics or co-occurring conditions or behaviors
conditions. Rather the goal has been to provide a basic
— and a careful matching of the medication treatment
introduction to medication treatment in general, stimu-
to the specific problems identified. A good doctor-
late readers to learn more about medication treatment,
patient relationship is critical to the success of any
and to enhance communication among physicians
pharmacological treatment effort. People are encour-
and the people with TS whom they treat. Readers are
aged to become knowledgeable about the medication
cautioned against taking and/or changing medications
they take and communicate fully with their clinicians.
based on information in this pamphlet (or any other
They should become active participants in their own
source) without first consulting their physicians.
treatment and follow-up so as to maximize benefit and minimize any adverse consequences of medication treatment. Lastly, it is important to understand that any medication not taken surely cannot be very effec-tive. Taking medication as it is prescribed is critical to optimal outcomes.
TSA gratefully acknowledges the counsel and guidance
Carol Mathews, M.D.
of its Medical Advisory Board. Members of the TSA
Medical Advisory Board welcome queries from col-
leagues and other professionals and can be reached by contacting the Tourette Syndrome Association, Inc. Tanya Murphy, M.D. McKnight Brain Institute John T. Walkup, M.D., Chairman
Johns Hopkins University School of MedicineBaltimore, MD
Paul Sandor, M.D. University of Toronto Cheston M. Berlin, Jr., M.D.
The Milton S. Hershey Medical CenterHershey, PA
Lawrence Scahill, MSN, Ph.D. Yale Child Study Center Cathy Budman, M.D.
North Shore University Hospital Manhasset, NY
Douglas W. Woods, Ph.D. University of Wisconsin Leon S. Dure, M.D. Samuel H. Zinner, M.D. University of Washington School of Medicine Donald L. Gilbert, M.D., M.S.
Cincinnati Children’s Hospital Cincinnati, OH
Jorge L. Juncos, M.D.
Emory University School of MedicineAtlanta, GA
John T. Walkup, M.D Katie Kompoliti, M.D.
Chair, TSA Medical Advisory Board, Professor,
Rush Presbyterian/St. Luke’s Medical Center
Division of Child and Adolescent Psychiatry, Johns
Hopkins Medical Institutions, Baltimore, MD
James T. McCracken, M.D.
I wish to thank Lawrence Scahill, MSN, Ph.D. for his
valuable assistance in the writing of this publication.
This publication is an adaptation of a previous one written by Dr. Gerald Erenberg, M.D., former chair of the TSA Medical Advisory Board.
Permission to reprint this publication in any form must be obtained from the national
Additional TSA resources - Videos & Vignettes HBO Documentary ”I have Tourette’s But Tourette’s Doesn’t Have Me”
HBO documentary originally aired November 12, 2005. Childen with TS. 27 min. plus 30 min. extras. AV-9 After the Diagnosis . . . The Next Steps
Produced expressly for individuals and families who have received a new diagnosis of TS. This video was developed to help clarify what TS is, to offer encouragement, and to dispel misperceptions about having TS. Features several families in excerpts from the Family Life With TS A Six-Part Series who recount their own experiences as well as comments from medical experts. Narrated by Academy Award Winner Richard Dreyfuss. 35 min. AV-10 The Complexities of TS Treatment: A Physicians’ Roundtable
Three internationally recognized TS experts, Drs. Cathy Budman, Joseph Jankovic and John Walkup provide colleagues with valuable information about the complexities of treating and advising families with TS. Emphasis is on different clinical approaches to patients with a broad range of symptom severity. Co-morbid and associated conditions arecovered. 15 min. AV-10a Clinical Counseling: Towards an Understanding of Tourette Syndrome
Targeted to counselors, social workers, educators, psychologists and families, this video features expert physicians, allied professionals and several families summarizing key issues that can arise when counseling families with TS. Includes valuable insights from the vantage point of those who have TS and those who seek to help them. 15 min. AV-11 Family Life With Tourette Syndrome . . . Personal Stories . . . A Six-Part Series
Adults, teenagers, children, and their families . . . all affected by Tourette Syndrome describe lives filled with triumphs and setbacks . . . struggle and growth. Informative and inspirational, these stories present universal issues and resonate with a sense of hope, possibility, and love. 58 min.
An up-to-date Catalog of Publications and Videos
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