Canadian Guidelines for the Treatment of Tics/Tourettes

Question 1

at what age does tic severity generally peak

Answer 1

age 11

Question 2

what % of people with tics will have comorbid OCD

Answer 2

about 35%

(up to 90% will have obsessive-compulsive symptoms)

Question 3

what is the most commonly comorbid condition with tics

Answer 3

ADHD (50%)

Question 4

what is a first line psychosocial treatment for tics

Answer 4

education and support for the patients family and school

Question 5

might tics get worse despite treatment?

Answer 5

yes, because they wax and wane over time

Question 6

name a behavioural therapy used to reduce repetitive behaviors, including tics

Answer 6

habit reversal therapy

Question 7

what are the two primary medication classes used to treat tics

Answer 7

alpha 2 agonists

antipsychotics

Question 8

why might CBIT not be suitable for everyone

Answer 8

availability limited by lack of well trained practitioners familiar with this approach

cost

requires patient active participation and tolerance of distress

Question 9

is there a clear consensus about which of the pharmacological treatments for tics should be trialled first

Answer 9

no

consider the least intrusive with lowest risk for adverse effects–> generally means guanfacine or clonidine first, before moving to antipsychotics and tetrabenazine

antipsychotics are the most effective however

Question 10

all antipsychotics listed in the guidelines received a “weak recommendation”; which were the only 3 with “high quality evidence”

Answer 10

risperidone

haloperidol

pimozide

Question 11

what two non-antipsychotic medications have strong recommendations for treatment of tics

Answer 11

guanfacine and clonidine (both have moderate quality evidence)

Question 12

list other non-antipsychotics medications listed in the guidelines for treatment of tics

Answer 12

topiramate

baclofen

botulinum toxin injections

tetrabenazine

(all are weak recommendations and very low/low quality evidence)

Question 13

are cannabinoids recommended in the treatment of tics

Answer 13

no–> no evidence to support this

low quality evidence that may help in adults

Question 14

what medications are NOT recommended in the treatment of tics

Answer 14

cannabinoids

keppra

IVIG

mecamylamine

fluoxetine

ondansetron

Question 15

what three interventions should be considered first line treatment for tics

Answer 15

behaivoural therapy

clonidine

guanfacine

Question 16

in which patients are botulinum toxin injections considered first line

Answer 16

adults with severe motor tics affecting eyes or face, or severe vocal tics such as coprolalia

Question 17

name the two second line therapies for tics

Answer 17

risperidone

aripiprazole

Question 18

list third line therapies for tics

Answer 18

pimozide

fluphenazine

haloperidol

ziprasidone

Question 19

do medications alter the natural history of tic disorders

Answer 19

no–> suppress tics in the present (ie if meds stopped, disorder will return)

Question 20

what is the recommendation grade for habit reversal therapy for tics?

Answer 20

strong recommendation, high quality evidence

Question 21

what is the recommendation grade for ERP for tics?

Answer 21

strong recommendation, low quality evidence

Question 22

is ERP also first line for tics?

Answer 22

yes, per the guidelines along with HRT

Question 23

which is preferred–HRT or ERP for tics

Answer 23

HRT–> more evidence

but HRT requires a skilled therapist

Question 24

behavioural therapies are unlikely to be helpful in kids below what age

Answer 24

likely below age 9

(or in kids with severe, untreated ADHD)

Question 25

is there evidence for DBS or rTMS for treating tics

Answer 25

guidelines say insufficient evidence for adults and not recommended in kids