What are the alternative treatment options for a 14-year-old boy with a tic disorder who has shown minimal response to 40mg of fluoxetine (selective serotonin reuptake inhibitor) and experiences fatigue as a side effect?

Treatment Options for Tic Disorder in a 14-Year-Old Boy on Fluoxetine

For a 14-year-old boy with tic disorder showing minimal response to fluoxetine 40mg and experiencing fatigue, the recommended alternative treatment is alpha-2 adrenergic agonists (clonidine or guanfacine) as first-line pharmacological therapy. 1

First-Line Pharmacological Options

Alpha-2 Adrenergic Agonists

• Clonidine

  • Starting dose: 0.1mg daily
  • Titrate gradually based on response
  • Monitor for: hypotension, sedation, fatigue
  • Advantages: "around-the-clock" effects, uncontrolled substance

• Guanfacine

  • Starting dose: 1mg daily
  • Extended-release formulation available (Intuniv)
  • Less sedating than clonidine
  • Monitor for: hypotension, fatigue, irritability

Alpha-2 agonists are particularly beneficial for tic disorders and have been identified as possible first-line options for patients with tics/Tourette's disorder 1. These medications typically take 2-4 weeks to show effects.

Second-Line Options

Atypical Antipsychotics

If alpha-2 agonists are ineffective or not tolerated, consider:

• Aripiprazole

  • Starting dose: 5mg daily
  • Can be effective for motor and vocal tics with fewer side effects than traditional antipsychotics
  • Studies show motor tic symptoms decreased by 66% and vocal tic symptoms by 26% within eight weeks 2
  • Monitor for: abdominal pain, fatigue, increased emotional sensitivity

• Risperidone

  • Low doses (0.5-2mg daily)
  • Monitor for: weight gain, metabolic effects, sedation

Non-Stimulant ADHD Medications

If ADHD symptoms are also present:

• Atomoxetine
  • Starting dose: 0.5mg/kg/day
  • Target dose: 1.2mg/kg/day
  • While generally considered safe for tic disorders, there are rare case reports of tic exacerbation 3
  • Monitor for: liver function, suicidal ideation

Management Considerations

Addressing Current Medication

1. Fluoxetine taper:

   • Gradually taper fluoxetine over 1-2 weeks to avoid withdrawal symptoms
   • Consider whether the patient has comorbid OCD or depression requiring continued SSRI treatment

2. Fatigue management:

   • If continuing fluoxetine is necessary for comorbid conditions, consider morning dosing
   • Avoid medications with high sedation potential

Monitoring Parameters

• Regular assessment of tic severity using standardized scales
• Monitor blood pressure and heart rate, particularly with alpha-2 agonists
• Assess for emergence of new side effects
• Follow-up every 2-4 weeks initially, then every 1-3 months once stable

Special Considerations

• Stimulant medications (methylphenidate, amphetamines) were traditionally avoided in patients with tics but recent evidence suggests they may not necessarily worsen tics in most patients 4, 5
• If comorbid ADHD is present and significantly impairing, consider adding a stimulant after tics are stabilized on alpha-2 agonists
• The combination of an alpha-2 agonist with a stimulant can be particularly effective for patients with both ADHD and tics 4

Non-Pharmacological Approaches

• Comprehensive Behavioral Intervention for Tics (CBIT)
• Habit reversal training
• Stress management techniques
• Regular sleep schedule and adequate sleep hygiene

Remember that tics often wax and wane naturally, so careful monitoring is essential to distinguish medication effects from the natural course of the disorder.