1) We are all concerned about potential side effects of medications for tics, especially in children. I am always on the look out for "real world" pragmatic data that can help us make rational choices about medication and tell us how effective it is likely to be - drug trials lasting only weeks or months have a habit of overestimating the value of individual medications.

 

Here is a Canadian study in which 73 children who were taking the newer kind of neuroleptic (atypical antipsychotics) for tics were closely followed for an average of over three years.

A significant number of important side effects were recorded. The most common were abnormalities of lipids in the blood (i.e. cholesterol and other fats). This occured in almost half, is a well known problem with some of these drugs and was more common in boys and in overweight children. Getting overweight was also an issue in half of the children. Three children developed neurological side effects.

 

One of the most commonly used drugs at the moment is aripiprazole - it is in this group of drugs but it is known to have fewer metabolic side effects. However, this study underlines the need for caution with all use of drugs. We need to weight up the benefits with the side effects and in the case of TS this can be difficult, we never really know how beneficial a drug will be for a particular person until they try it.

 

2) We know that adult members of Tourettes Action sometimes wonder if all the interest is in children and not them. TS in adults is also less well documented in the medical literature. This week a new study from Dr. Jankovic's group in Texas has compared children with TS with adults.

Most of the adults with TS of course developed TS as a child, but there are a few that seem to get it for the first time in adulthood. In fact, this situation doesn't technically fulfil diagnostic criteria for TS, which by definition starts by the age of 18. In this study there were 43 adults of whom 35 had first had tics under the age of 18 whilst 8 had adult onset, with 2 having onset over the age of 50. Compared to children, the adults had more tics of the face and trunk, were more likely to have had depression or drug problems, but had less vocal tics and ADHD. The latter confirms that the most usual evolution as people get older is for the the overall syndrome to improve- but there are of course exceptions to this, and adults with more severe TS are probably more likely to be members of Tourettes Action than adults whose TS has improved significantly.

 

This study doesn't tell us a great deal, but it is important to further investigate factors that make improvement with ageing more likely, and any mechanisms that makes TS in adults different to TS in children.

 

3) Another study from Dr. Jankovic from earlier in the year - a trial of a drug that is normally used for epilepsy and migraine, called topiramate.

 

This is worth mentioning as the title includes the magic words "a randomised, double-blind, placebo-controlled study". As discussed before, this means that one can put more weight on the results as they are less likely to be due to chance or the placebo effect. In both children and adults this drug was found to be helpful for tics and doesn't belong to the normal groups of drugs that we use.

 

Having heard that, what are some of the questions we need to ask to decide how useful this result really is?

 

Firstly, how was the improvement in the patients measured, as measuring tics is difficult. The investigators used a standard measure called the Yale Global Tic Severity Scale, which improved by 14 points on the drug compared to 5 points for placebo "dummy" pills. For some patients this may have meant a lot, for others they may not have actually felt much better despite the improvement in the numbers.

 

Secondly, how long did the trial go on for? This figure is not included in the abstract. In the paper it says that once the drug was started patients were monitored for less than 12 weeks. So while we can't reject the idea of topiramate being a useful option, this statistically sound study doesn't reflect real world pragmatic medicine- how many children or adults have experienced a drug for tics being useful initially with the benefit later wearing off? We need to know whether the drug was still helpful many more months down the line.