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

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.

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

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