1. Athetosis, dystonia, tics
Domina Petric, MD

2. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Athetosis and dystonia
There is no satisfactory medical treatment.
Some patients respond
to levodopa medication:
dopa-responsive dystonia.
Some patients with dystonia
respond to diazepam, amantadine,
antimuscarinic drugs in high dose,
carbamazepine, baclofen, haloperidol
or phenothiazines.
Katzung, Masters, Trevor. Basic and clinical pharmacology.

3. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Athetosis
Katzung, Masters, Trevor. Basic and clinical pharmacology.

4. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Patients with focal
dystonias (blepharospasm,
torticollis) often benefit from
injection of botulinum
toxin into the overactive
muscles.
Deep brain stimulation may be helpful
in medically intractable cases.
Katzung, Masters, Trevor. Basic and clinical pharmacology.

5. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Chronic multiple tics: Gilles de la Tourette´s syndrome.
Symptomatic treatment for severe disorder.
Tics
Education of patients, family and teachers is important!
Katzung, Masters, Trevor. Basic and clinical pharmacology.

6. Katzung, Masters, Trevor. Basic and clinical pharmacology.
A common pharmacologic
approach is haloperidol.
Start dose: 0,25 or 0,5 mg daily.
Gradual dose increase: by 0,25 mg every 4 or 5 days.
Total daily maintenance dose: 3-8 mg.
Katzung, Masters, Trevor. Basic and clinical pharmacology.

7. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Adverse effects of haloperidol: extrapyramidal movement disorders, sedation, dryness of the mouth, blurred vision, gastrointestinal disturbances.
Katzung, Masters, Trevor. Basic and clinical pharmacology.

8. Katzung, Masters, Trevor. Basic and clinical pharmacology.
HALOPERIDOL
PIMOZIDE
TICS
OTHER
CLONIDINE
GUANFACINE
Katzung, Masters, Trevor. Basic and clinical pharmacology.

9. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Tics
Pimozide is dopamine receptor antagonist.
It may be helpful in patients as a first-line treatment or in those who are either unresponsive to or intolerant of haloperidol.
Start dose: 1 mg/day.
Dosage is increased by 1 mg every 5 days.
Most patients require 7-16 mg/day.
It has similar side effects to haloperidol.
Pimozide may also cause irregularities of cardiac rhythm.
Katzung, Masters, Trevor. Basic and clinical pharmacology.

10. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Tics
Certain α-adrenergic agonists may be preferred as an initial treatment: these agents are less likely to cause extrapyramidal side effects than neuroleptic agents.
Clonidine reduces motor or vocal tics in about 50% of children so treated.
Reduction of activity in noradrenergic neurons of locus caeruleus.
Start dose: 2-3 mcg/kg/day.
Dose is increased after 2 weeks to 4 mcg/kg/day.
It may cause initial transient fall in blood pressure.
Katzung, Masters, Trevor. Basic and clinical pharmacology.

11. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Tics
The most common adverse effect of clonidine is sedation.
Other adverse effects include reduced or excessive salivation and diarrhea.
Guanfacine (α-agonist)
Katzung, Masters, Trevor. Basic and clinical pharmacology.

12. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Tics
Phenotiazines (fluphenazine)
Atypical antipsychotics (risperidone, aripiprazole): patients with significant behavioral problems.
Clonazepam, carbamazepine
Injection of botulinum toxin A at the site of problematic tics
Treatment of associated attention deficit disorder: clonidine patch, guanfacine, pemoline, methylphenidate, dextroamphetamine
Obsessive-compulsive disorder: SSRIs, clomipramine
Deep brain stimulation
Katzung, Masters, Trevor. Basic and clinical pharmacology.

13. Katzung, Masters, Trevor. Basic and clinical pharmacology.
Literature
Katzung, Masters, Trevor. Basic and clinical pharmacology.
Medscape.com
Katzung, Masters, Trevor. Basic and clinical pharmacology.