What medications can help decrease the severity of tics in a pediatric patient with a tic disorder?

Medications for Decreasing Tic Severity in Pediatric Patients

Alpha-2 adrenergic agonists (clonidine or guanfacine) should be your first-line pharmacological choice for treating tics in children, particularly when ADHD or sleep disorders are comorbid, as they provide around-the-clock effects and are uncontrolled substances with a favorable safety profile. 1

When to Consider Medication vs. Behavioral Therapy

• Behavioral interventions (habit reversal training and exposure with response prevention) must be attempted first before any pharmacological treatment, as they are the gold standard first-line approach for tics in children 1, 2, 3
• Pharmacotherapy should only be considered when tics are impairing daily functioning, causing social problems, accompanied by other neuropsychiatric symptoms, or when the patient is unlikely to benefit from behavioral therapy 2
• Nearly half of patients experience spontaneous remission by age 18, making watchful waiting reasonable in milder cases 1

First-Line Pharmacological Options: Alpha-2 Adrenergic Agonists

Start with clonidine or guanfacine as your initial medication choice 1:

• These medications are particularly advantageous when comorbid ADHD or sleep disorders are present, as they may improve both conditions simultaneously 1
• Expect 2-4 weeks until therapeutic effects are observed 1
• Monitor pulse and blood pressure regularly during treatment 1
• Common adverse effects include somnolence, fatigue, and hypotension; administer in the evening to minimize daytime sedation 1
• Clonidine is available in adhesive patch formulations for convenience 4

Second-Line Options: Antipsychotic Medications

If alpha-2 agonists fail or tics remain severe, consider anti-dopaminergic medications 1:

Atypical Antipsychotics (Preferred Over Typical Agents)

Risperidone 1:

• Initial dose: 0.25 mg daily at bedtime
• Maximum: 2-3 mg daily in divided doses
• Monitor for extrapyramidal symptoms at doses ≥2 mg daily
• Avoid coadministration with other QT-prolonging medications

Aripiprazole 1:

• Demonstrated 56% positive response at 5 mg versus 35% on placebo in pediatric RCTs (ages 6-17)
• Flexible dosing range: 5-15 mg/day
• Significant improvements in irritability, hyperactivity, and stereotypy subscales

Olanzapine and Quetiapine 1:

• Olanzapine: Initial dose 2.5 mg daily at bedtime
• Quetiapine: Initial dose 12.5 mg twice daily
• Diminished risk of extrapyramidal symptoms compared to typical antipsychotics

Typical Antipsychotics (Use With Caution)

Do not use typical antipsychotics as first-line due to higher risk of irreversible tardive dyskinesia 1:

• Haloperidol and pimozide are effective but carry significant side effect burden 1, 4
• Pimozide requires cardiac monitoring due to significant QT prolongation risk 1
• Never use benztropine or trihexyphenidyl for managing extrapyramidal symptoms in this population 1

Critical Management of Comorbid ADHD

When ADHD coexists with tics (present in 50-75% of children with Tourette's), specific medication choices matter 1, 5:

• Atomoxetine or guanfacine are strongly preferred as they may improve both ADHD and tics simultaneously 1
• Stimulants can be used safely in children with tics and ADHD—multiple double-blind placebo-controlled studies show stimulants are highly effective for ADHD in these patients, and in the majority, tics do not increase 6, 1
• Amphetamine-based medications may worsen tic severity compared to methylphenidate when treating comorbid ADHD 1
• If tics worsen markedly on a stimulant, switch to an alternative stimulant or add an alpha-agonist like clonidine or guanfacine 6

Defining Treatment-Refractory Cases

A patient is considered treatment-refractory only after failing ALL of the following 1:

1. Behavioral techniques (habit reversal training, exposure and response prevention)
2. Therapeutic doses of at least three proven medications, including:
   • Anti-dopaminergic drugs
   • Alpha-2 adrenergic agonists

Advanced Treatment for Severe Cases

Deep brain stimulation (DBS) is reserved exclusively for severe, treatment-refractory cases with significant functional impairment 1, 5:

• Only recommended for patients above 20 years of age due to uncertainty about spontaneous remission 1
• Targets include centromedian-parafascicular thalamus and globus pallidus interna 1
• Approximately 97% of patients show improvement in published studies 5
• Requires comprehensive neurological, neuropsychiatric, and neuropsychological assessment by a multidisciplinary team 1

Critical Pitfalls to Avoid

• Do not withhold stimulants in children with ADHD and tics based on outdated concerns—the evidence clearly supports their safe use 6, 1
• Do not use typical antipsychotics as first-line due to higher risk of irreversible tardive dyskinesia 1
• Ensure stable, optimized treatment for comorbidities for at least 6 months before considering advanced interventions like DBS 1
• Screen for obsessive-compulsive behaviors (present in 30-60% of cases), which may require separate treatment 1, 5
• Start with low doses and titrate gradually to minimize side effects with all antipsychotic medications 1

Monitoring and Follow-Up

• Assess health-related quality of life using disease-specific instruments (e.g., GTS-QOL) as patient wellbeing is the primary treatment motive 1
• Monitor for treatment adherence and psychosocial factors that could compromise outcomes 1
• Document the impact on function and quality of life, as this is crucial for assessing treatment response 1