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Use of stimulants to treat comorbid attention-deficit/hyperactivity disorder (ADHD) in patients with tics is controversial because of FDA warnings against it based on limited, case-report evidence. The contraindication is understandable because stimulants increase dopamine availability, whereas drugs used to treat tics lower dopamine activity. But in children with comorbid ADHD and tic disorders, ADHD symptoms often cause worse cognitive and social impairment than tics, thereby increasing interest in stimulant treatment.
To ascertain whether there is a data-based reason to avoid stimulants, researchers conducted a meta-analysis of tic onset or worsening among 2385 participants in 22 published, double-blind, placebo-controlled, English-language trials of stimulants in children under age 18. Onset or worsening of tics occurred in 5.7% of participants on stimulants and 6.5% of those on placebo. The pooled relative risk was 0.99 with active drug. Onset or worsening was not associated with dose, short- or long-acting preparations, duration of treatment, or patient age.
Cohen SC et al. Meta-analysis: Risk of tics associated with psychostimulant use in randomized, placebo-controlled trials. J Am Acad Child Adolesc Psychiatry 2015 Jun 30; [e-pub]. (http://dx.doi.org/10.1016/j.jaac.2015.06.011)
Comment
This finding has far-reaching significance because about half of patients with tics have comorbid ADHD and about 20% of ADHD patients have tic disorders. These data provide strong support for using therapeutic doses of methylphenidate or amphetamine preparations in tic patients. Clinicians need to be mindful that supratherapeutic doses of amphetamine are associated with increased tics (NEJM JW Pediatr Adolesc Med Nov 2009 and J Am Acad Child Adolesc Psychiatry 2009; 48:884). Families aware of the FDA warnings can be informed that worsening of tics while on stimulants is most likely due to the natural waxing and waning of tic disorders. One proviso is that long-term effects of stimulants on tics are unknown.