Pharmacotherapy for Tourette syndrome in children
Pharmacotherapy should be prescribed by a clinician with expertise in using psychotropics in children—follow the principles of psychotropic use in children.
Pharmacotherapy may be considered for Tourette syndrome if tics cause pain or injury, cause sustained academic, social or emotional difficulties for the child, or interfere significantly with the child’s functioning in other areas. However, pharmacotherapy rarely achieves complete suppression of all tics; instead, treatment aims to reduce the tic frequency and severity sufficiently, without causing significant adverse effects.
Effective treatment of comorbid attention deficit hyperactivity disorder (ADHD) and obsessive compulsive disorder (OCD) symptoms may help reduce tic severity.
If drug therapy is considered appropriate for Tourette syndrome, clonidine is used first line because, despite being less efficacious than antipsychotics, it is not associated with significant adverse effects. Clonidine may be more effective for Tourette syndrome in children with comorbid ADHD, and can also have beneficial effects on ADHD symptoms. Use:
clonidine (5 years or older) 50 micrograms orally, daily. Increase the daily dose, according to response and tolerability, by no more than 50 micrograms (increase the dose or frequency of dosing) at intervals of 3 days, until optimal response is obtained or a daily dose of 300 micrograms (in up to 4 divided doses) is reached1 . Usual daily dose 3 to 5 micrograms/kg in divided doses. If a dose increase does not provide additional improvement of symptoms, use the minimum effective dose. Tourette syndrome clonidine
Although slowly increasing the dose of clonidine (as above) limits sedation and hypotension, routinely measure blood pressure and pulse rate during treatment. Avoid stopping treatment suddenly because of the risk of rebound hypertension.
If Tourette syndrome is not well controlled with clonidine, consider using an antipsychotic. Antipsychotics with some evidence for reducing tic severity include risperidone and aripiprazole2 . There is limited evidence for ziprasidone for reducing tic severity. Haloperidol has some evidence of efficacy for Tourette syndrome, but its use is limited by its risk of extrapyramidal adverse effects. Pimozide is no longer used due to cardiovascular adverse effects.
Discuss the following with the patient and their family, carers or significant others so they can make an informed decision about antipsychotic use:
- the purpose, limitations and risks associated with antipsychotic use and the importance of combining an antipsychotic with nonpharmacological interventions
- which antipsychotic adverse effects are acceptable to the patient and how these effects are monitored, prevented and addressed; children appear to be more prone to adverse effects of antipsychotics, including extrapyramidal, endocrine and metabolic adverse effects—the long-term effects of antipsychotics in prepubertal children are uncertain.
If antipsychotic therapy is agreed upon, perform baseline tests to guide antipsychotic choice and to give a reference point for future monitoring. For a schedule for monitoring antipsychotic adverse effects, see here.
If an antipsychotic is considered appropriate for treatment of tics in Tourette syndrome, use:
1 risperidone (child 7 years or older) 0.25 to 0.5 mg orally, daily. Assess the patient’s response to therapy to determine the need for dose adjustment. If needed, increase the daily dose by no more than 0.5 mg every 5 days. Maximum dose of 3 mg daily in 2 divided doses. Regularly review the need for continued treatment Tourette syndrome risperidone
OR
2 aripiprazole Tourette syndrome aripiprazole
child 6 years or older and less than 50 kg: 2.5 mg orally, daily for 2 days, then increase to 5 mg daily. Assess the patient’s response to therapy to determine the need for dose adjustment. If needed, increase the daily dose by no more than 2.5 mg per week. Maximum dose 10 mg daily. Regularly review the need for continued treatment
child 6 years or older and 50 kg or more: 2.5 mg orally, daily for 2 days, then increase to 5 mg daily for 5 days, then increase to 10 mg daily. Assess the patient’s response to therapy to determine the need for dose adjustment. If needed, increase the daily dose by no more than 5 mg per week. Maximum dose 15 mg daily. Regularly review the need for continued treatment
OR
3 haloperidol (child 5 years or older) 0.25 to 0.5 mg orally, twice daily. Assess the patient’s response to therapy to determine the need for dose adjustment. If needed, increase the daily dose by no more than 0.25 mg per week. Usual therapeutic dose is 0.05 mg/kg. Maximum dose 3 mg daily, in 2 or 3 divided doses. Regularly review the need for continued treatment. Tourette syndrome haloperidol
If a patient develops adverse effects while taking an antipsychotic, see here.