Pimozide

Orap

Only FDA-approved antipsychotic for the treatment of tics

- Cardiac changes (in the QT interval)- One double-blind study found Pimozide superior to Haloperidol with respect to efficacy and side effects

- muscular rigity, drooling, tremor, lack of facial expression, slow movement, and restlessness

Haloperidol

Haldol

- 4% per year risk of tardive dyskinesia in younger patients, higher in those over 45

- depression resulting in suicide is common during long-term treatment

- musular rigity, drooling, tremor, lack of facial expression, slow movement, and restlessness

Fluphenazine

Prolixin

- Seemingly less common side effects than other neuroleptics

Sulpiride

Not approved in US and Canada

Dopamine blocker

Anti-psychotic

- fewer extrapyramidal side effects than many of the older antipsychotic medications

Thioridazine

-Mellaril

-Novorizadine

-Thioril

- Can prolong QT interval (lead to sudden death)

Risperidone

Risperdal

-Dopamine and serotonin blocking properties

-effective compared to placebo

-at least as effective as Clonidine

-Some reports say it can help OCD, others say it exacerbates symptoms

-Shown to be effective in reducing tic frequency and intensity in most, but not all, studies

- Can prolong QT interval (lead to sudden death)

- Tardive Dyskinesia

Olanzapine

Zyprexa

Dopamine-2 and serotonin-2A and -2C antagonism

- "Some improvement" (Budman, Gayer, Lesser, Qiuhu Shi, Bruun)

- Sedation

- Weight gain

- Increased appetite

- Dry mouth

- Transient asymptomatic hypoglycemia

Thiothixene

Navane

Clozapine

Clozaril

- Patient developed invluntary movements during treatment with clozapine and fluvoxamine

Quetiapine

Seroquel

blocks D1 and D2 receptors, and 5-HT2A, 5-HT2C, 5-HT1A, 5-HT1D, and alpha receptors

Found to decrease tic severity by 35% compared with a 7% change in placebo

Ziprasidone

Geodon

Found to significantly reduce tic frequency and count over placebo

-Cardiac changes in the QT interval

-Prolonged QT interval can cause ventricular fibrillation and sudden death

-Less likely to cause weight gain

Aripiprazole

Abilify

Tardive dyskinesia

Sertraline

Zoloft

- Movement disorder side-effects (Lambtert, Trutia, Petty)

Fluoxetine

- Movement disorder side-effects (Lambtert, Trutia, Petty)

- Exacerbate tics in a patient with TS but was found to have no effect on tics in a small, double blind, placebo-controlled crossover trial

Paroxetine

- Movement disorder side-effects (Lambtert, Trutia, Petty)

- One case of Paroxetine worsening tics in a 12 year old boy with TS

Fluvoxamine

Luvox

- Most often used to treat OCD

- One of few SSRIs to have monocyclic structure

- Improvement in 21% of patients with OCD and chronic tics, 52% response rate in patients with OCD and NO tics (source )

- Normal SSRI side effects

- Single case of this drug causing TS in a patient being treated for OCD (source)

- Akathasia, dyskinesia

- Cases of Fluvoxamine worsening tics

Citalopram

Celexa

- shows to "significantly reduce tics in TS in one small study"

- No reports to date of this agent exacerbating tic symptoms

- No evidence directly impolicating Citalopram with teeth grinding (bruxism)

Escitalopram

- Examined in depressed, but not OCD

Nefazodone

Serzone (Discontinued by Bristol-Myers Squibb in US and Canada in 2004; generic formulations are still available)

Blocks post-synaptic serotonin type-2A receptors and, to a lesser extent, by inhibiting pre-synaptic serotonin and norepinephrine (noradrenaline) reuptake. Also a relatively potent alpha-1 adrenoceptor antagonist

Unlike most SNRIs and SSRIs, Nefazodone has no negative effects on libido or sexual functioning

Bupropion

Wellbutrin, Zyban

Norepinephrine and dopamine reuptake inhibitor, and nicotinic antagonist

- found to exacerbate tics in four children with TS

- no reports of it improving tics

Clomipramine

Anafranil

- Strong, but not completely selective serotonin reuptake inhibitor, as the primary active metabolite desmethylclomipramine acts preferably as a norepinephrine reuptake inhibitor

- Alpha blockage, beta receptor downregulation, and postsynaptic antagonism on histamine H1 receptors and dopamine receptors have also been noted

- downregulation of NMDA receptors

Tricyclic antidepressant

- higher incidence of seizures than seen with other tricyclic antidepressants

- No benefit found for Clomipramine or desipramine for patients with TS

- Reported to worsen motor tics in one case with OCD and schizoid personality disorder

Nortriptyline

Inhibits reuptake of norepinephrine and to a lesser extent, serotonin

- shown to improve tic symptoms in a chart review of 12 cases of children with tics and ADHD

Imipramine

-Antideprin

-Deprenil

-Deprimin

-Deprinol

-Depsonil

-Dynaprin

-Eupramin

-Imipramil

-Irmin

-Janimine

-Melipramin

-Surplix

-Tofranil

-Norepinephrine reuptake inhibition (strong)

- Serotonin reuptake inhibition (moderate to strong)

- Acetylcholine antagonist at M2 muscarinic acetylcholine receptors

- Epinephrine - antagonizes adreno-receptors (II)

- Dopamine reuptake and release at D1 and D2 receptors ("similar to but less potent than the psychostimulants, dopamine agonists and atypical antidepressant buproprion on dopaminergic mechanisms (increase in release and blockage of reuptake inhibition")***

- Opiates and Enkephalinase - low activity

- Histamine antagonist at H1 receptors. Acute sedative effects

(all data in this cell from wikipedia)

- *** says it's similar on dopamine to Buproprion, which has been known to exaverbate tics

- reported to decrease tics in one TS case and have no effect on TS symptoms in another

fever, chills, cough, weight loss, irregular heart rhythms, weight gain (in contrast to weight loss, mentioned earlier), sexual side effects, tremor has been frequently reported, headache, confusion, aggressiveness, weakness, sudden muscle spasms

Clonidine hydrochloride

Catapres

- Alpha 2-adrenergic agonist

- °62- agonist

-may take time to build up in the system before it begins working

- also used to treat ADHD

- combined with Ritalin reduced the severity of a child's tics with 75% showing improvement

- more effective in reducing motor tics than reducing vocal tics (Nass & Bressman, 2002)

- 11% of patients had significant improvement, 14% had moderate improvement, 67% of subjects had no improvement or worsening

- another study showed no statistical improvements in tic distribution, frequency, or severity

- another placebo controlled double blind study confirmed that Clonidine is effective in lessening tics

-Dry mouth

-Drowsiness

Guanfacine

Tenex

- Alpha 2-adrenergic agonist

- °62- agonist

- a study found a significant decrease in the severity of motor and phonic tics

- double bline study of guanfacine for tics and ADHD found a 31% decrease in tic severity compared to placebo

-Dry mouth

-Drowsiness (less than Clonidine)

Tetrabenazine

Not approved by the FDA as a treatment for tics

Approved by FDA for use in US on 8/15/08?

- Blocks dopamine receptors

-Dopamine depleter

-Monoamine - depleting

- Produced significant tic amelioration in over half the patients followed for over two years (Jankovic and Beach, 1997)

- "Powerful anti-tic drug"

- Does not cause tardive dyskinesia

- Given to 5 patients, 2 had good results, 3 had no improvement but experienced side effects

- 57.4% improvement in 47 patients with tics in an open label study (Jankovic and Beach)

-Parkinsonism, sedation, akathisia, depression

Pergolide

withdrawn from US market on 3/30/2007

- on the premise that dopamine agonists in very low dosages preferentially act on the presynaptic receptors and thereby decrease dopamine release…

- success on a trial group that was unresponsive to neuroleptics suggests that in these patients the improvement due to pergolide is not linked to an effect on D2-receptors-carrying GABAergic neurons, as usually assumed, because the patients did not respond to neuroleptics acting in this way. In these 3 cases, unlike in other TD patents, a prevalent action of pergolide by pre-synaptic inhibition of dopamine release on D1-receptors-carrying GABAergic neurons is suggested. (source)

- In an open-label study of 32 patients, there was a 50% reduction in tics in 24 patients.

- In a randomized double-blind placebo-controlled crossover study with 24 subjects, 19 completed. Statistically significant reductions with few side effects

- this is an older Parkinson’s drug

- in 2003, reported to be associated with a form of heart disease called cardiac fibrosis

Talipexole

-dopamine agonist

-also has alpha-adrenergic agonist activity

- tested on 13 subjects with TS. 5 dropped out, 4 experienced intolerable side effects

.- Blinded evaluation of videotapes failed to show any statistically significant improvement in tic frequency or severity

- Not recommended for standard treatment for TS

Atomoxetine (formally known as Tomoxetine)

Strattera

- After 2-3 weeks of treatment, a patients mother reported reduction in tics and vocal tics eliminated. AHDH improved (source)

- Two children with ADHD developed tics while on Atomoxetine that did not fully resolve upon discontinuation (Parraga, Parraga, Harris)

- upset stomach, sporadic nausea, sudden vomiting

- sexual side effects

Reboxetine

Selective Norepinephrine Reuptake Inhibitor

Desipramine

-Norpramin

-Pertofrane

Can prolong QT interval (lead to sudden death)

Marijuana

- significant reduction in tics in two studies (Mueller-Vahl, 2003)

Marinol

- some patients clearly benefit when taking Marinol at a doseage of 2.5 to 10mg twice a day

Nifedipine

ProcardiaXL

Acts on slow calcium channels invascular smooth muscle and myocardium, producing vasodilation

decrease in tic symptoms. 10mg 3 times daily

- dizziness, giddiness, headache, autonomic flushing, warmth, sweating, nasal congestion, sore throat

- nausea, constipation, flatulence

- dyspnea, cough, hpotension, wheezing, tachycardia, arrhythmias, fever, heart failure, muscle cramping

Verapamil

Isoptin

inhibits calcium transport into myocardialand vascular smooth muscle cells, resulting in inhibition of excitation contraction coupling and subsequent contraction

decrease in motor tics, improvement in mood, 20mg 3 times daily

- dizziness, headache, fatigue, constipation, abdominal discomfort

- bradycardia, hypotension, edema, heart block, sinus arrest, pulmonary edema

Clonazepam

Klonopin (USA), Rivotril, Ravotril, or RIvatril, elsewhere

- GABA receptor antagonist

-sometimes useful in managing tics "since some of the premonitory sensations resemble obsessions and the tics may be viewed as 'compulsive' movements, anti-OCD medications also may be helpful"

Sedation, weight gain, impaired academic performance, social anxiety with school refusal in children and a worsening of attention in children with comorbid ADHD

Levetiracetam

Keppa

"antiepileptic drug with atypical mechanisms of action"

All 60 patients showed improvement (Awaad, Michon, Minarik)

- hair loss

- pins and needles sensation

- psychiatric symptoms ranging from irritability to depression

- headache

- nausea

Topiramate

Topamax

- the reduction in tics in some patients may be explained by its potentiation of GABA activity

- can be used for OCD

- no reports of it exacerbating movement disorders

- change in taste, pins and needles, cognitive deficiency, difficulty understanding concepts

- loss of appetits

- somnolence

- nausea

- upper respiratory tract infection

- osteroporosis

Lamotrigine

occasionally reported to cause tics, but they resolved completely within a month following cessation of the drug. Tics reappeared with the introduction of lamotrigine

Carbmazepine

Reported to worsen tics in 8 patients while improving them in 1

Associated with the development of other movement disorders

Propoxyphene

Naltrexone

Vivitrol (USA), Revia, Depade (elsewhere)

-significant lessening of tics after treatment than with placebo

-reported to improve symptoms of TS, but also reports of it worsening TS

Oxycodone

Carisoprodol

Soma

Centrally-acting muscle relaxant whose active metabolite is meprobamate

Propranolol

Inderal

Non-selective beta blocker