Pharmacological Treatment for Co-occurring Tourette's Syndrome, ADHD, and OCD
Primary Treatment Recommendation
Initiate treatment with an alpha-2 agonist (guanfacine extended-release or clonidine) as first-line therapy, as this addresses both tics and ADHD symptoms simultaneously without exacerbating any of the three conditions. 1
Treatment Algorithm
First-Line: Alpha-2 Agonists
Start with guanfacine extended-release 1-4 mg daily (particularly beneficial if sleep disturbances are present) or clonidine (requires twice-daily dosing, though a transdermal patch is available for improved adherence). 1 Both medications require 2-4 weeks to achieve full therapeutic effect. 1 This approach has Level A evidence for treating TS with comorbid ADHD, making it the strongest evidence-based choice. 2
- Monitor blood pressure and pulse at each visit, as these are critical safety parameters for alpha-2 agonists. 1
- Watch for somnolence/sedation, which is the most common adverse effect. 1
Second-Line: Add Atomoxetine for Persistent ADHD
If ADHD symptoms remain inadequately controlled after 4 weeks of optimized alpha-2 agonist dosing, add atomoxetine 60-100 mg daily for adults (maximum 1.4 mg/kg/day). 1 Atomoxetine provides "around-the-clock" effects without tic exacerbation and has demonstrated efficacy in TS with comorbid ADHD. 1, 2
- Screen for suicidality at each visit, especially during the first 3 months, as atomoxetine carries an FDA black box warning for increased suicidal ideation risk. 1
- Monitor blood pressure and heart rate at each visit. 1
Third-Line: Address OCD Symptoms with SSRI
For OCD symptoms, add an SSRI (sertraline or fluoxetine preferred) once tics and ADHD are stabilized. 1, 3 SSRIs are the drugs of choice for OCD in patients with Tourette syndrome. 4 The SSRI may also reduce stress sensitivity and emotional problems, potentially improving tic suppression through better self-regulatory abilities. 3
- Monitor for suicidal ideation, particularly if akathisia develops, as this is a critical safety concern when combining SSRIs with other medications. 1
Fourth-Line: Atypical Antipsychotic for Severe Tics
If tics remain severely impairing despite the above interventions, add an atypical antipsychotic such as aripiprazole or risperidone. 1 These medications have demonstrated efficacy for both tics and can augment OCD treatment when SSRIs provide only partial response. 5, 3
- Aripiprazole is FDA-approved for Tourette syndrome and may be particularly useful in selected cases. 2, 5
- Risperidone is recommended for augmentation in OCD with tics when OCS responds only partially to SSRIs. 3
Critical Pitfalls to Avoid
Do not start with stimulants as first-line therapy in this population. While methylphenidate can be used cautiously in TS with ADHD 4, 2, stimulants carry risk of tic exacerbation and should only be considered after alpha-2 agonists and atomoxetine have been optimized. 4
Do not assume a single medication will treat all three conditions. This is a sequential, symptom-targeted approach where you address the most impairing symptoms first (typically tics and ADHD together), then layer in OCD treatment. 1, 2
Do not use typical antipsychotics (haloperidol, pimozide) as first-line agents, despite their FDA approval for TS, due to their adverse effect profile compared to alpha-2 agonists and atypical antipsychotics. 5
Monitoring Schedule
- Weeks 1-4: Weekly visits to titrate alpha-2 agonist, monitor blood pressure/pulse, and assess for somnolence. 1
- Weeks 4-8: If adding atomoxetine, weekly suicidality screening and vital sign monitoring. 1
- Ongoing: Monthly visits once stabilized, with continued monitoring of blood pressure, pulse, suicidality, and symptom severity across all three domains. 1