What is the recommended dosing for Intuniv (guanfacine) in an adult patient with tics, considering their past medical history and comorbid conditions such as hypertension or cardiovascular disease?

Intuniv Dosing for Adults with Tics

For adults with tics, start guanfacine (Intuniv) at 0.5 mg at bedtime and titrate by 0.5 mg weekly as needed and tolerated to a maximum of 3-4 mg/day divided twice daily. 1

Initial Dosing Strategy

• Begin with 0.5 mg at bedtime to minimize somnolence and allow assessment of tolerability 1
• The bedtime dosing strategy helps mitigate sedation, which is one of the most common adverse effects 2
• This starting dose is lower than the FDA-labeled hypertension dose (1 mg) but appropriate for tic disorders where lower doses may be effective 2, 1

Titration Protocol

• Increase by 0.5 mg increments every week based on clinical response and tolerability 1
• The maximum effective dose is typically 3-4 mg/day, divided into twice-daily dosing for tic disorders 1
• Most therapeutic effect occurs at lower doses; adverse reactions increase significantly above 3 mg/day 2
• Guanfacine has a reasonable safety profile and is considered a first-line medication for moderate-severity tics 1

Critical Cardiovascular Monitoring Requirements

• Monitor blood pressure and heart rate regularly during dose escalation, as guanfacine causes modest reductions in both parameters 3
• Watch for hypotension, bradycardia, and cardiac conduction abnormalities, which require careful monitoring 3
• In patients with pre-existing hypertension or cardiovascular disease, guanfacine may actually provide dual benefit for both conditions, but requires closer monitoring 2
• Orthostatic hypotension can occur and may be delayed, sometimes appearing 30+ hours after dose changes 4

Special Considerations for Comorbid Conditions

Hypertension

• Guanfacine's antihypertensive effects may be beneficial in adults with both tics and hypertension 2
• However, combining guanfacine with clonidine is not recommended due to excessive cardiovascular depression risk, worsened sedation, and additive adverse effects 3
• If additional blood pressure control is needed, add a different class of antihypertensive rather than another alpha-2 agonist 3

Cardiovascular Disease

• Use with caution and implement more frequent monitoring in patients with cardiac disease 3
• QTc prolongation has been reported in overdose situations, though this is uncommon at therapeutic doses 4
• The medication must be tapered rather than abruptly discontinued to avoid rebound hypertension 3, 2

Discontinuation Protocol

• Never abruptly discontinue guanfacine—always taper to prevent rebound hypertension and withdrawal symptoms 3, 2, 5
• Taper by reducing the dose by 0.5-1 mg every 3-7 days 5
• Rebound hypertension with guanfacine occurs less frequently than with clonidine and is delayed 2-4 days after cessation, consistent with its longer half-life 2, 5
• In most cases, blood pressure returns to pretreatment levels slowly (within 2-4 days) without ill effects when properly tapered 2, 5

Common Pitfalls to Avoid

• Do not start at the FDA-labeled hypertension dose of 1 mg for tic disorders; this increases sedation risk and is unnecessary for efficacy 2, 1
• Do not combine with clonidine, as this creates predictably worse sedation, hypotension, bradycardia, dry mouth, and constipation 3
• Do not use once-daily dosing at higher doses for tic disorders; divided twice-daily dosing improves tolerability at the 3-4 mg/day range 1
• Do not overlook comorbid ADHD, anxiety, or OCD, which occur in >50% of patients with tics and may be more bothersome than the tics themselves 1
• Do not assume "controlled" cardiovascular disease makes this medication automatically safe—regular monitoring remains essential 3

Efficacy Expectations

• Guanfacine is less potent than dopamine receptor blockers (antipsychotics) but has a superior safety profile 1
• Reserve antipsychotics for severe, disabling tics that fail to respond to guanfacine 1
• Many mild tics do not require pharmacological treatment; education and reassurance may be sufficient 1