A 16-year-old boy comes to the office with a lengthy history of frequent episodes in which he "swears uncontrollably at others," according to his mother. The episodes are accompanied by blinking, grunting, and grimacing. The patient has tried habit reversal therapy with limited benefit and has been treated with guanfacine for the past year. His mother is concerned that, despite the medication, these episodes have progressively worsened, and she fears that he is bullied at school. The symptoms have affected his ability to take tests and socialize with others, leading to increased isolation and worsening academic performance. She asks if there is another medication that could help control his symptoms. Which of the following is the most appropriate pharmacotherapy for this patient?

Question

A 16-year-old boy comes to the office with a lengthy history of frequent episodes in which he "swears uncontrollably at others," according to his mother.  The episodes are accompanied by blinking, grunting, and grimacing.  The patient has tried habit reversal therapy with limited benefit and has been treated with guanfacine for the past year.  His mother is concerned that, despite the medication, these episodes have progressively worsened, and she fears that he is bullied at school.  The symptoms have affected his ability to take tests and socialize with others, leading to increased isolation and worsening academic performance.  She asks if there is another medication that could help control his symptoms.  Which of the following is the most appropriate pharmacotherapy for this patient?

Quizplus · Accepted Answer

11ec25c8_d810_d00c_bc81_8fca032c1db8_MD0003_00 Tourette disorder (TD) (also called Tourette syndrome) is characterized by multiple motor tics and at least one vocal tic with onset in childhood. Tics are usually preceded by irresistible urges and followed by feelings of relief. Although experienced as involuntary, tics can be suppressed voluntarily for some time. They are exacerbated by stress and fatigue. The most effective nonpharmacological treatment for TD is habit reversal training, a form of behavioral therapy. Pharmacotherapy can also be considered when habit reversal training is ineffective or unavailable, or when symptoms interfere with social, academic, or occupational functioning. Antidopaminergic agents are the most effective medications and include the dopamine-depleting agent tetrabenazine as well as antipsychotic agents that act as dopamine-receptor blockers (eg, risperidone, haloperidol). Alpha-2 adrenergic agonists (eg, guanfacine, clonidine) are also used, but the evidence is not as robust as that for antidopaminergic agents. (Choice A) Anticholinergic medications, such as benztropine, are used to treat and prevent extrapyramidal side effects associated with antipsychotics. They are not a treatment for TD. (Choices C, D, and F) Monoamine oxidase inhibitors are used in treatment-resistant major depression. Selective serotonin reuptake inhibitors and tricyclic antidepressants are used to treat depression as well as symptoms of obsessive-compulsive disorder, which is often comorbid with TD. These pharmacological agents do not play a primary role in the treatment of TD. (Choice E) Stimulant medications are used in the treatment of attention-deficit hyperactivity disorder (ADHD); however, this patient does not have ADHD as a comorbidity. Educational objective: Treatment options for Tourette disorder include habit reversal training, antidopaminergic agents, and alpha-2 adrenergic receptor agonists. References: Current approaches and new developments in the pharmacological management of Tourette syndrome. (http://www.ncbi.nlm.nih.gov/pubmed/29335879) Behavior therapy for Tourette syndrome: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23645295)

A 16-Year-Old Boy Comes to the Office with a Lengthy