European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment

Veit Roessner, Kerstin J Plessen, Aribert Rothenberger, Andrea G Ludolph, Renata Rizzo, Liselotte Skov, Gerd Strand, Jeremy S Stern, Cristiano Termine, Pieter J Hoekstra, ESSTS Guidelines Group, Christos Androutsos, Harald Aschauer, Gillian Baird, Netty Bos-Veneman, Ariana Brambilla, Francesco Cardona, Danielle C Cath, Andrea E Cavanna, Virginie Czernecki, Sandra Dehning, Alan Eapter, Luca Farkas, Julia Gadaros, Andreas Hartmann, Elizabeth Hauser, Isabel Heyman, Tammy Hedderly, Pieter J Hoekstra, Anne Korsgaard, Georgina M Jackson, Linnea Larsson, Andrea G Ludolph, Davide Martino, Claudia Menghetti, Nanette Mol Debes, Norbert Muller, Kirsten Muller-Vahl, Alexander Munchau, Tara Murphy, Richard Musil, Peter Nagy, Judith Nurnberger, Ben Oostra, Perry Paschou, Massimo Pasquini, Kerstin J Plessen, Mauro Porta, Hugh Rickards, Renata Rizzo, Mary M Robertson, Veit Roessner, Aribert Rothenberger, Domenico Servello, Liselotte Skov, Jeremy S Stern, Gerd Strand, Zsannett Tarnok, Cristiano Termine, Jolande Van der Griendt, Cara Verdellen, Veerle Visser-Vandewalle, Ebba Wannag, Tomas Wolanczyck, Veit Roessner, Kerstin J Plessen, Aribert Rothenberger, Andrea G Ludolph, Renata Rizzo, Liselotte Skov, Gerd Strand, Jeremy S Stern, Cristiano Termine, Pieter J Hoekstra, ESSTS Guidelines Group, Christos Androutsos, Harald Aschauer, Gillian Baird, Netty Bos-Veneman, Ariana Brambilla, Francesco Cardona, Danielle C Cath, Andrea E Cavanna, Virginie Czernecki, Sandra Dehning, Alan Eapter, Luca Farkas, Julia Gadaros, Andreas Hartmann, Elizabeth Hauser, Isabel Heyman, Tammy Hedderly, Pieter J Hoekstra, Anne Korsgaard, Georgina M Jackson, Linnea Larsson, Andrea G Ludolph, Davide Martino, Claudia Menghetti, Nanette Mol Debes, Norbert Muller, Kirsten Muller-Vahl, Alexander Munchau, Tara Murphy, Richard Musil, Peter Nagy, Judith Nurnberger, Ben Oostra, Perry Paschou, Massimo Pasquini, Kerstin J Plessen, Mauro Porta, Hugh Rickards, Renata Rizzo, Mary M Robertson, Veit Roessner, Aribert Rothenberger, Domenico Servello, Liselotte Skov, Jeremy S Stern, Gerd Strand, Zsannett Tarnok, Cristiano Termine, Jolande Van der Griendt, Cara Verdellen, Veerle Visser-Vandewalle, Ebba Wannag, Tomas Wolanczyck

Abstract

To develop a European guideline on pharmacologic treatment of Tourette syndrome (TS) the available literature was thoroughly screened and extensively discussed by a working group of the European Society for the Study of Tourette syndrome (ESSTS). Although there are many more studies on pharmacotherapy of TS than on behavioral treatment options, only a limited number of studies meets rigorous quality criteria. Therefore, we have devised a two-stage approach. First, we present the highest level of evidence by reporting the findings of existing Cochrane reviews in this field. Subsequently, we provide the first comprehensive overview of all reports on pharmacological treatment options for TS through a MEDLINE, PubMed, and EMBASE search for all studies that document the effect of pharmacological treatment of TS and other tic disorders between 1970 and November 2010. We present a summary of the current consensus on pharmacological treatment options for TS in Europe to guide the clinician in daily practice. This summary is, however, rather a status quo of a clinically helpful but merely low evidence guideline, mainly driven by expert experience and opinion, since rigorous experimental studies are scarce.

Figures

Fig. 1
Fig. 1
Decision tree for the treatment of tic disorders including Tourette syndrome. Indications for treatment are given in “Tics cause subjective discomfort (e.g. pain or injury)”, “Tics cause sustained social problems for the patient (e.g. social isolation or bullying)”, “Tics cause social and emotional problems for the patient (e.g. reactive depressive symptoms)” and “Tics cause functional interference (e.g. impairment of academic achievements)”. Solid arrow next level of evaluation/treatment, dashed-dotted arrow monitoring after successful treatment, dashed arrow alternating between two treatment options. Note: patient preference (after psychoeducation) and availability of therapists have to be considered in the choice of treatment. DBS deep brain stimulation, THC Tetrahydrocannabinol
Fig. 2
Fig. 2
Evaluation of treatment efficacy in TS in light of natural waxing and waning. At date 1 a therapeutic intervention could be followed by tic reduction despite of its potential to increase tics or without an effect on tics. This has to be ascribed not to causal mechanisms of the intervention but to the natural waxing and waning of the tics. Correspondingly, a therapeutic intervention at date 2 could be followed by an increase of TS symptomatology despite its potential to reduce tics. The therapeutic intervention might attenuate the natural waxing of the tics. Conclusion: Meaningful appraisal of treatment efficacy in TS can only be given in most cases after longer time

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