European clinical guidelines for Tourette syndrome and other tic disorders—version 2.0. Part III: pharmacological treatment

Abstract

In 2011, the European Society for the Study of Tourette Syndrome (ESSTS) published the first European guidelines for Tourette Syndrome (TS). We now present an update of the part on pharmacological treatment, based on a review of new literature with special attention to other evidence-based guidelines, meta-analyses, and randomized double-blinded studies. Moreover, our revision took into consideration results of a recent survey on treatment preferences conducted among ESSTS experts. The first preference should be given to psychoeducation and to behavioral approaches, as it strengthens the patients’ self-regulatory control and thus his/her autonomy. Because behavioral approaches are not effective, available, or feasible in all patients, in a substantial number of patients pharmacological treatment is indicated, alone or in combination with behavioral therapy. The largest amount of evidence supports the use of dopamine blocking agents, preferably aripiprazole because of a more favorable profile of adverse events than first- and second-generation antipsychotics. Other agents that can be considered include tiapride, risperidone, and especially in case of co-existing attention deficit hyperactivity disorder (ADHD), clonidine and guanfacine. This view is supported by the results of our survey on medication preference among members of ESSTS, in which aripiprazole was indicated as the drug of first choice both in children and adults. In treatment resistant cases, treatment with agents with either a limited evidence base or risk of extrapyramidal adverse effects might be considered, including pimozide, haloperidol, topiramate, cannabis-based agents, and botulinum toxin injections. Overall, treatment of TS should be individualized, and decisions based on the patient’s needs and preferences, presence of co-existing conditions, latest scientific findings as well as on the physician’s preferences, experience, and local regulatory requirements.

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“…These as well as non-genetic factors (such as perinatal events and immunological factors) are likely to contribute to the heterogeneity of the clinical phenotype, the structural and functional brain anomalies, and the neural circuitry involvement ( 4 ). Recently, the European Society for the study of Tourette Syndrome (ESSTS) wrote guidelines for the management of TS recommending psychoeducation as the initial intervention, and behavior therapy (BT) as a first-line intervention when psychoeducation alone is insufficient ( 9 ). Two approaches, habit reversal training (HRT; and its expanded version, Comprehensive Behavioral Intervention for Tics; CBIT) and exposure with response prevention (ERP), have gatered the strongest empirical support.…”

Medical Cannabis for Gilles de la Tourette Syndrome: An Open-Label Prospective Study

“…Therapy for GTS is tailored to the frequency and severity of symptoms. The most recent therapy guidelines have been published by the American Academy of Neurology (AAN) in 2019 [ 9 ] and the European Society for the Study of Tourette Syndrome (ESSTS) in 2021 [ 10 – 12 ]. Behavioral therapy, such as comprehensive behavioral intervention for tics (CBIT), is safe and effective and should be considered as an initial treatment choice.…”

“…In the recent AAN guideline recommendation summary [ 9 ], cannabis-based therapies were suggested to have limited evidence to reduce tic severity, although, where regional legislation allows, physicians may consider treatment with CBM in otherwise treatment-resistant adults with clinically relevant tics (level C). Recent ESSTS guidelines state that in resistant cases, treatment with agents with limited evidence base could be considered, such as CBM [ 12 ]. This is also illustrated in the ESSTS algorithm for the treatment of tics suggesting considering alternative medication, such as CBM, in patients who do not respond appropriately to behavioral therapy and to various pharmacotherapies [ 11 ].…”

Updated European guidelines for Tourette syndrome: and now use them!

“…This focused issue of European Child and Adolescent Psychiatry contains fully updated guidelines for the assessment and treatment of Tourette syndrome, written by European experts. The articles provide very useful practical recommendations for optimal care of children and adolescents with a tic disorder, spanning assessment, [1] psychological interventions [2], pharmacological treatments [3], and deep brain stimulation [4]. Recommendations are not only based on evidence from clinical trials but also took clinical experience into account to fill the existing gaps of evidence.…”