What is the best approach to manage a patient with Attention Deficit Hyperactivity Disorder (ADHD) and Tourette's syndrome who is currently taking Focalin XR (dexmethylphenidate)?

Management of ADHD with Focalin XR in a Patient with Tourette's Syndrome

Continue Focalin XR (dexmethylphenidate) with close monitoring for tic emergence or worsening, as the FDA label explicitly requires assessment and regular monitoring for tics before and during treatment, and the largest randomized controlled trial demonstrates that methylphenidate does not worsen tics more than placebo in most patients with comorbid Tourette's. 1, 2

Evidence Supporting Continued Stimulant Use

The FDA label for dexmethylphenidate (Focalin XR) specifically addresses this clinical scenario. Before initiating treatment, clinicians must assess family history and clinically evaluate patients for tics or Tourette's syndrome, then regularly monitor for emergence or worsening of tics during treatment, discontinuing only if clinically appropriate. 1 This guidance acknowledges that stimulants can be used in patients with tics, but requires vigilant monitoring rather than absolute avoidance.

The most robust evidence comes from a multicenter, randomized, double-blind trial of 136 children with ADHD and chronic tic disorder. Methylphenidate treatment resulted in tic worsening in only 20% of patients—no higher than the 22% rate observed with placebo—and measured tic severity actually lessened in the methylphenidate group compared to baseline. 2 This landmark study fundamentally changed clinical practice by demonstrating that prior recommendations to avoid methylphenidate in patients with tics were unsupported by evidence.

Monitoring Requirements

Monitor blood pressure and pulse at baseline and regularly during treatment, as stimulants can increase both parameters. 3, 1

Track height and weight closely in pediatric patients, as CNS stimulants are associated with growth suppression (approximately 2 cm less height and 2.7 kg less weight over 3 years). 1

Systematically assess tic frequency and severity at each visit using standardized measures, documenting any changes from baseline. 1

Alternative Treatment Options if Tics Worsen

If tics demonstrably worsen on Focalin XR despite adequate ADHD symptom control, consider the following algorithm:

First-line alternative: Alpha-2 agonists (clonidine or guanfacine) have Level A evidence for treating ADHD with comorbid Tourette's syndrome and may actually improve tic severity. 4, 5, 2 The multicenter trial showed that clonidine lessened tic severity while effectively treating ADHD symptoms, particularly impulsivity and hyperactivity. 2

• Clonidine dosing requires twice-daily administration and causes sedation in 28% of patients (moderate to severe). 2
• Guanfacine offers once-daily dosing with potentially better tolerability. 3
• Both require 2-4 weeks to achieve full therapeutic effect, unlike stimulants which work within days. 3

Second-line alternative: Atomoxetine is a selective norepinephrine reuptake inhibitor that may be used as first-line treatment in patients with comorbid tics or Tourette's disorder. 3, 4, 5 However, atomoxetine requires 6-12 weeks for full effect and has smaller effect sizes (approximately 0.7) compared to stimulants (1.0). 3

Third-line consideration: Combined therapy with clonidine plus methylphenidate produced the greatest ADHD symptom improvement in the multicenter trial (p < 0.0001 vs placebo) and resulted in the greatest reduction in tic severity among all treatment groups. 2 This combination addresses both conditions simultaneously but requires careful monitoring for sedation and cardiovascular effects.

Critical Clinical Pitfalls to Avoid

Do not automatically discontinue effective stimulant therapy based solely on the presence of Tourette's syndrome without documented tic worsening. 1, 2 The evidence demonstrates that most patients tolerate stimulants well, and untreated ADHD significantly impairs quality of life.

Do not use dextroamphetamine (Adderall) as the alternative stimulant if switching is necessary, as the controlled trial showed dextroamphetamine produced sustained tic increases at higher doses, while methylphenidate-associated tic exacerbations attenuated over time. 6

Avoid benzodiazepines for any comorbid anxiety in this population, as they may reduce self-control and have disinhibiting effects. 7

Never use MAO inhibitors concurrently with stimulants due to risk of hypertensive crisis; allow at least 14 days between discontinuation of an MAOI and initiation of stimulants. 7, 1

Multimodal Treatment Approach

Implement behavioral therapy and psychosocial interventions alongside pharmacological treatment, as guidelines consistently recommend multimodal approaches for ADHD with comorbid conditions. 3, 7 Nonpharmacological interventions should be tried before escalating pharmacological treatment. 4

Provide psychoeducation to the patient and family about the expected course of treatment, the evidence supporting stimulant use in Tourette's syndrome, and the specific monitoring plan. 3

Special Considerations for This Patient

The presence of comorbid Tourette's syndrome does not contraindicate stimulant use but does require heightened vigilance. The majority of patients with ADHD and Tourette's syndrome experience improvement in ADHD symptoms with acceptable effects on tics when treated with methylphenidate. 6 Only a substantial minority have consistent worsening of tics on stimulants, and these effects are reversible in all cases. 6

If tics are currently well-controlled and not causing functional impairment, prioritize ADHD treatment with continued Focalin XR, as comorbid ADHD symptoms often have a more significant influence on quality of life than tics alone. 4