What medication can be added to Concerta (methylphenidate) to reduce oral tics?

Medications for Reducing Oral Tics Associated with Concerta (Methylphenidate)

Alpha-agonists such as clonidine or guanfacine should be added first to reduce oral tics in patients taking Concerta (methylphenidate). 1

First-Line Options for Tic Management with Concerta

• Alpha-agonists are recommended as first-line medications for managing tics in patients on stimulants due to their reasonable safety profile 1

  • Clonidine: Start with 0.05 mg at bedtime, increase as needed by 0.05 mg every 4-7 days to a maximum of 0.3-0.4 mg/day divided three or four times daily 2
  • Guanfacine: Start with 0.5 mg at bedtime, increase as needed by 0.5 mg weekly to a maximum of 3-4 mg/day divided twice daily 2

• Alpha-agonists offer the dual benefit of potentially treating both ADHD symptoms and tics simultaneously 1, 3

Evidence Supporting Alpha-Agonists

• Multiple studies have demonstrated that alpha-agonists not only don't worsen tics but can actually improve them when used alone or in combination with stimulants 3, 4

• In a randomized controlled trial, the combination of clonidine and methylphenidate showed the greatest benefit for reducing tic severity compared to either medication alone or placebo 4

• Alpha-agonists have been specifically approved "as adjunctive therapy to stimulant medications" in the USA, which can increase treatment effects and/or decrease adverse effects of stimulants 1

Second-Line Options

If alpha-agonists are ineffective or not tolerated:

• Atomoxetine can be considered as it has been shown to reduce ADHD symptoms without worsening tics 1, 3, 5

  • Clinical trials found that tics did not worsen under treatment with atomoxetine 1

• For more severe tics that don't respond to alpha-agonists, atypical antipsychotics may be considered 1, 2:

  • Risperidone: Usually first choice, starting at 0.01 mg/kg/dose once daily, increasing by 0.02 mg/kg/day at weekly intervals up to 0.06 mg/kg/dose once daily 2
  • Ziprasidone and olanzapine are reasonable alternatives 2

Administration Considerations

• When adding clonidine or guanfacine to Concerta, administration in the evening is generally preferable due to the relatively frequent occurrence of somnolence/fatigue as an adverse effect 1

• For patients with sleep disturbances in addition to tics, clonidine and guanfacine may offer additional benefits 1

Monitoring and Side Effects

• Common side effects of alpha-agonists include:

  • Hypotension, sedation/somnolence, dizziness, dry mouth, headache, fatigue 1
  • These medications should not be stopped abruptly if used for more than 9 weeks to avoid rebound hypertension, tachycardia, and hypertonia 1

• If using atypical antipsychotics, monitor for weight gain, metabolic changes, and extrapyramidal symptoms 2

Clinical Approach Algorithm

1. Confirm that tics are significantly bothersome and require treatment (many mild tics don't require specific medication) 2
2. Start with alpha-agonist (clonidine or guanfacine) at low dose and titrate gradually 1, 2
3. If inadequate response after optimal dosing, consider atomoxetine 1, 5
4. For severe, treatment-resistant tics, consider atypical antipsychotics 1, 2
5. Regularly monitor for side effects and efficacy, adjusting doses as needed

Remember that tics may wax and wane naturally, so careful assessment of medication effects is important to distinguish from natural fluctuations in tic severity 2.