For a patient with tics, do you recommend using regular Intuniv (guanfacine) or the extended-release formulation for treatment?

Guanfacine Extended-Release for Tics

Use extended-release guanfacine (Intuniv) rather than immediate-release formulations for treating tics, as the extended-release preparation provides once-daily dosing with more stable drug levels and is the FDA-approved formulation for pediatric neuropsychiatric conditions. 1

Rationale for Extended-Release Formulation

Extended-release guanfacine is strongly preferred over immediate-release for tic disorders because:

• Once-daily dosing improves adherence compared to the multiple daily doses required with immediate-release formulations, which is particularly important in pediatric populations 1
• More stable plasma concentrations throughout the day reduce peak-related adverse effects like sedation while maintaining therapeutic efficacy 1
• The FDA approval for pediatric use specifically references the extended-release formulation, providing regulatory support for this approach 1

Dosing Protocol for Tics

Start with 1 mg once daily in the evening, then titrate by 1 mg weekly based on response and tolerability to a target range of 0.05-0.12 mg/kg/day (maximum 4-7 mg/day) 1, 2

• Evening administration is preferable to minimize daytime somnolence, which occurs in approximately 10-39% of patients depending on dose 1, 3
• The typical effective dose range is 1-4 mg/day for tic disorders 2, 4

Efficacy Considerations

Guanfacine demonstrates modest efficacy for tics with response rates of approximately 19% in controlled trials, which is substantially lower than clonidine (68.9%) or antipsychotics like risperidone (62.5%) or aripiprazole (88.6%) 5

• A recent 8-week randomized controlled trial showed no significant difference between extended-release guanfacine and placebo, with only 19% positive response on Clinical Global Impressions-Improvement versus 22% for placebo 6
• Guanfacine is better tolerated than antipsychotics but less effective for tic suppression 5
• Therapeutic effects require 2-4 weeks to emerge, unlike the immediate effects of some other medications 1

When to Choose Guanfacine for Tics

Guanfacine should be selected as first-line treatment specifically when:

• Tics co-occur with ADHD, as guanfacine treats both conditions simultaneously without worsening tics 1, 2
• Tics co-occur with sleep disturbances, as evening dosing addresses insomnia while providing around-the-clock symptom control 1
• The patient cannot tolerate or has contraindications to more potent antipsychotic medications 2, 5

For moderate-to-severe tics without ADHD comorbidity, clonidine or antipsychotics (risperidone, aripiprazole) demonstrate superior efficacy 2, 5, 7

Critical Safety Monitoring

Obtain baseline blood pressure and heart rate before initiating guanfacine, then monitor at each dose adjustment 1

• Expect modest decreases in blood pressure (1-4 mmHg) and heart rate (1-2 bpm) 1
• Never abruptly discontinue guanfacine—taper by 1 mg every 3-7 days to avoid rebound hypertension 1
• Monitor for excessive somnolence (10-39%), fatigue (9-15%), dry mouth (10-54%), and constipation (5-16%), which are dose-dependent 1, 3

Common Pitfalls

• Do not expect immediate tic reduction—counsel families that 2-4 weeks are required for therapeutic effects 1
• Do not use immediate-release guanfacine for chronic tic management, as the multiple daily doses reduce adherence and increase peak-related side effects 1
• Do not overlook comorbid ADHD, OCD, anxiety, or sleep disorders, which occur in >50% of patients with tics and often cause more distress than the tics themselves 2, 7