From the Guidelines
Stimulant-induced dyskinesia or tics can be managed through dose reduction or discontinuation of the causative stimulant medication, as symptoms often resolve when the stimulant is eliminated or decreased. The provided evidence 1 suggests that stimulant-related side effects, including dyskinesia and tics, are often responsive to dose or timing adjustments.
Management Strategies
- Consider dose reduction or discontinuation of the stimulant medication, as this often leads to resolution of symptoms 1
- Switching to a different stimulant formulation may help, such as changing from immediate-release to extended-release methylphenidate or trying lisdexamfetamine instead of mixed amphetamine salts
- For persistent symptoms, adding alpha-2 agonists like clonidine (0.1-0.4 mg/day) or guanfacine (1-4 mg/day) can be effective while allowing continued stimulant treatment
- In more severe cases, low-dose antipsychotics such as risperidone (0.25-1 mg/day) or aripiprazole (2-5 mg/day) may be necessary, as they work by blocking dopamine receptors and counteracting excessive dopaminergic activity caused by stimulants
Monitoring and Adjunctive Therapies
- Regular monitoring for side effects is essential, particularly metabolic changes with antipsychotics 1
- Drug holidays from stimulants during weekends or school breaks can also help reduce the risk of developing or worsening dyskinesia or tics
- Behavioral interventions like Comprehensive Behavioral Intervention for Tics (CBIT) may provide additional benefit as adjunctive therapy, although the provided evidence does not specifically support this approach, it is a common practice in clinical settings.
It is crucial to weigh the benefits and risks of stimulant therapy and adjust the treatment plan accordingly to minimize the risk of dyskinesia and tics, as severe movement disorders are very rare but can be serious 1.
From the Research
Treatment Options for Stimulant-Induced Dyskinesia or Tics
- The treatment options for dystonia, a hyperkinetic movement disorder, include drugs, botulinum toxin, and deep brain stimulation surgery 2.
- For tardive dyskinesia, a type of hyperkinetic movement disorder, the vesicular monoamine transporter 2 (VMAT2) inhibitors, such as tetrabenazine, deutetrabenazine, and valbenazine, are considered the treatment of choice for most patients 3.
- Other treatment options for tardive dyskinesia include amantadine, clonazepam, Gingko biloba, zolpidem, botulinum toxin, and deep brain stimulation 3.
- Deep brain stimulation has been shown to be effective in treating medication-induced tardive dyskinesia and/or dystonia, with a mean improvement of 77.5% in the severity of the movement disorders 4.
- Deep brain stimulation has also been used to treat hyperkinetic disorders, including dystonia, tardive dyskinesia, and tics, with encouraging results 5.
Specific Treatments for Tics
- Botulinum toxin may be helpful for treating focal dystonia and some forms of tardive dystonia, including tics 6.
- Deep brain stimulation of the globus pallidus internus (GPi) has been shown to be effective in treating primary dystonia, generalized or not, and may also be effective in treating tics 5.
- Stimulation of the centre-median/parafascicular nucleus of the thalamus and GPi stimulation (ventromedial) have demonstrated efficacy in treating Gilles de la Tourette's syndrome, a condition characterized by tics 5.
Considerations for Treatment
- Treatment of stimulant-induced dyskinesia or tics must be individualized and based on the severity, phenomenology, potential side effects, and other factors 3.
- The choice of treatment should take into account the underlying cause of the dyskinesia or tics, as well as the patient's medical history and current medications 3, 6.