Acute dystonia with low-dosage aripiprazole in Tourette's disorder

Oculogyric Crisis Due to Aripiprazole Ingestion as a Suicide Attempt: A Case Report

Oculogyric crisis (OGC) is a rare type of acute dystonia characterized by spasmodic upward deviation of the eyes lasting for a few minutes to several hours. It is commonly seen with the administration of first-generation antipsychotics and rarely reported in patients taking second-generation antipsychotics. Although aripiprazole, a second-generation antipsychotic, is known for its low potential for extrapyramidal side effects (EPS), there are multiple case reports of it resulting in acute dystonia, especially OGC. In this paper, we report a case of aripiprazole-induced OGC in a 16-year-old female patient after a suicide attempt by taking 40 mg of aripiprazole and 5 g of acetaminophen. The necessary investigations were ordered, and the patient's dystonic symptoms resolved completely after administering parenteral diazepam and benztropine.

Oculogyric Crisis after Initiation of Aripiprazole: A Case Report of an Active Duty Service Member

Introduction

Oculogyric crisis is an acute dystonic reaction characterized by sustained, bilateral, and upward deviation of the eyes. It is a relatively uncommon extrapyramidal side effect of antipsychotic medications. Aripiprazole is an atypical antipsychotic that is FDA-approved for the treatment of schizophrenia, bipolar disorder, Tourette's disorder, and treatment resistant major depressive disorder. Compared to other antipsychotics, it is thought to have a lower propensity for causing dystonic side effects. Clinical Case. This case report is of a 19-year-old male who was psychiatrically hospitalized for first episode psychosis and initiated on low-dose oral aripiprazole. Three days after initiation of the medication, the patient was found to be markedly anxious and pacing around his room. Exam was notable for intermittent upward eye rolling, sustained upward conjugate gaze, and limited downward gaze. No other facial dyskinetic movements were observed. Treatment. The patient's oral aripiprazole was held, and he was administered 50 mg of oral diphenhydramine with improvement in symptoms within one hour. Ocular symptoms, dizziness, frontal headache, and pacing were resolved the following morning. He declined reinitiation of an antipsychotic medication.

Conclusion

Aripiprazole-induced acute dystonia, specifically OGC, is a rare potential adverse effect of aripiprazole. Risk factors include male gender, young age, use of typical antipsychotics, and initiation or uptitration of an antipsychotic. Even though atypical antipsychotics including aripiprazole are associated with lower risk for extrapyramidal symptoms, the possibility of oculogyric dystonia merits close monitoring especially in young, male, and drug naive patients. Anticholinergic agents such as diphenhydramine can treat symptoms of acute dystonia.

Aripiprazole-Induced Oculogyric Crisis: A Pediatric Case Series and A Brief Narrative Review

Oculogyric crisis (OGC) represent an unusual type of dystonic movement disorder, usually reported as an adverse event of antipsychotic drugs, with acute or tardive onset, likely due to a functional disruption of dopaminergic neurotransmission. It is seldom reported in children with aripiprazole, an atypical antipsychotic commonly used in youths. In this manuscript, we report on a case series of three pediatric patients and provide a brief narrative review of the literature, in order to increase the awareness of clinicians and to foster future research in this area.

Safety of aripiprazole for tics in children and adolescents: A systematic review and meta-analysis

BACKGROUND

Aripiprazole is widely used in the management of tic disorders (TDs), we aimed to assess the safety of aripiprazole for TDs in children and adolescents.

METHODS

A systematic literature review was performed in the databases of MEDLINE, Embase, the Cochrane Library and 4 Chinese databases, from inception to February 2019. All types of studies evaluating the safety of aripiprazole for TDs were included. The quality of studies was assessed using the Cochrane Risk of Bias tool, the Newcastle-Ottawa Scale tool, the National Institute of Clinical Excellence, the CARE (Case Report) guidelines according to types of studies. Risk ratio (RR) and incidence rate with a 95% confidence interval (CI) were used to summarize the results.

RESULTS

A total 50 studies involving 2604 children met the inclusion criteria. The result of meta-analysis of randomized controlled trials showed that there was a significant difference between aripiprazole and haloperidol with respect to rate of somnolence (RR = 0.596, 95% CI: 0.394, 0.901), extrapyramidal symptoms (RR = 0.236, 95% CI: 0.111, 0.505), tremor (RR = 0.255, 95% CI: 0.114, 0.571), constipation (RR = 0.148, 95% CI: 0.040, 0.553), and dry mouth (RR = 0.141, 95% CI: 0.046, 0.425). There was a significant difference between aripiprazole and placebo in the incidence rate of adverse events (AEs) for somnolence (RR = 6.565, 95% CI: 1.270, 33.945). The meta-analysis of incidence of AEs related to aripiprazole for case series studies revealed that the incidence of sedation was 26.9% (95% CI: 16.3%, 44.4%), irritability 25% (95% CI: 9.4%, 66.6%), restlessness 31.3% (95% CI: 13%, 75.1%), nausea and vomiting 28.9% (95% CI: 21.1%, 39.5%), and weight gain 31.3% (95% CI: 10.7%, 91.3%).

CONCLUSION

Aripiprazole was generally well tolerated in children and adolescents. Common AEs were somnolence, headache, sedation, nausea, and vomiting. Further high-quality studies are needed to confirm the safety of aripiprazole for children and adolescents with TDs.

Update on the Pharmacological Treatment of Tics with Dopamine-Modulating Agents

More than 40 years of research and clinical practice have proven the effectiveness of dopamine receptor antagonists in the pharmacological treatment of tics. A blockade of the striatal dopamine-D2 receptors is mainly responsible for their tic-reducing effect. A broad spectrum of dopamine-modulating agents, such as typical and atypical antipsychotics, but also dopamine receptor agonists are used with an immanent discord between experts about which of them should be considered as first choice. The present Review outlines the state of the art on pharmacological treatment of tics with dopamine-modulating agents by giving an systematic overview of studies on their effectiveness and a critical discussion of their specific adverse effects. It is considered as an update of a previous review of our research group published in 2013. The Review closes with a description of the current resulting treatment recommendations including the results of a first published revised survey on European expert's prescription preferences. Based on the enormously growing evidence on its effectiveness and safety, aripiprazole currently seems to be the most promising agent in the pharmacological treatment of tics. Furthermore, benzamides (especially tiapride), which are commonly used in Europe, have proven their excellent effectiveness-tolerability profile over decades in clinical practice and are therefore also highly recommended for the treatment of tics. Nevertheless, pharmacological treatment of tics remains an indiviual choice depending on each patient's own specific needs.

Oculogyric crises: A review of phenomenology, etiology, pathogenesis, and treatment

Oculogyric crises are a rare movement disorder characterized by paroxysmal, conjugate, tonic, usually upwards, deviation of the eyes. Causes for oculogyric crises are limited and include complications of dopamine-receptor blocking medications and neurometabolic disorders affecting dopamine metabolism, suggesting that an underlying hypodopaminergic state is important to the pathogenesis. Mimickers of oculogyric crises exist, and we propose diagnostic criteria to distinguish true oculogyric crises. Recognition of oculogyric crises is important for the diagnosis and appropriate treatment of rare disorders, and an approach to investigations in oculogyric crises is proposed. © 2017 International Parkinson and Movement Disorder Society.

Aripiprazole Improves Associated Comorbid Conditions in Addition to Tics in Adult Patients with Gilles de la Tourette Syndrome

Gilles de la Tourette Syndrome (GTS) is characterized by motor and vocal tics, as well as associated comorbid conditions including obsessive-compulsive disorder (OCD), attention deficit/hyperactivity disorder (ADHD), depression, and anxiety which are present in a substantial number of patients. Although randomized controlled trials including a large number of patients are still missing, aripiprazole is currently considered as a first choice drug for the treatment of tics. The aim of this study was to further investigate efficacy and safety of aripiprazole in a group of drug-free, adult patients. Specifically, we investigated the influence of aripiprazole on tic severity, comorbidities, premonitory urge (PU), and quality of life (QoL). Moreover, we were interested in the factors that influence a patient's decision in electing for-or against- pharmacological treatment. In this prospective uncontrolled open-label study, we included 44 patients and used a number of rating scales to assess tic severity, PU, comorbidities, and QoL at baseline and during treatment with aripiprazole. Eighteen out of fortyfour patients decided for undergoing treatment for their tics with aripiprazole and completed follow-up assessments after 4–6 weeks. Our major findings were (1) aripiprazole resulted in significant reduction of tics, but did not affect PU; (2) aripiprazole significantly improved OCD and showed a trend toward improvement of other comorbidities including depression, anxiety, and ADHD; (3) neither severity of tics, nor PU or QoL influenced patients' decisions for or against treatment of tics with aripiprazole; instead patients with comorbid OCD tended to decide in favor of, while patients with comorbid ADHD tended to decide against tic treatment; (4) most frequently reported adverse effects were sleeping problems; (5) patients' QoL was mostly impaired by comorbid depression. Our results suggest that aripiprazole may improve associated comorbid conditions in addition to tics in patients with GTS. It can be hypothesized that these beneficial effects are related to aripiprazole's adaptive pharmacological profile, which exhibits an influence on the dopaminergic as well as a number of other neurotransmitter systems. For the first time, our data provide evidence that patients' decision making process for or against medical treatment is influenced by other factors than tic severity and QoL.

Facial spasms, but not hemifacial spasm: a case report and review of literature

INTRODUCTION

Facial spasms represent a complicated array of neurological motor disorders with unique diagnostic and treatment algorithms. Due to the rarity of many of these disorders in the pediatric population, special care must be taken in identifying subtle differences in presentation of these disorders.

METHODS

We present a case of a 3-year-old boy diagnosed with a brainstem ganglioglioma, Chiari 1 malformation, and a 2-year history of left-sided facial spasms. Stereotyped facial contractions and subtle eye deviation occurred every 10 s, with downward movement rather than upward elevation of the eyebrow.

RESULTS

MRI revealed absence of a clear compressive vessel of the centrally-myelinized portion of the facial nerve, and EMG of the left facial nerve demonstrated no abnormal motor response or evidence of "lateral spread." Given these findings, a diagnosis of hemifacial seizures was made. Microvascular decompression was not recommended, and botulinum toxin injection was not pursued; however, the patient has remained refractory to antiepileptic drugs, possibly due to biochemical alteration by his ganglioglioma. He may eventually require surgical debulking should his symptoms progress.

CONCLUSION

Hemifacial spasm is a well-recognized disorder, but similar conditions can, at times, imitate its appearance. While our patient presented with facial spasms, his clinical history, examination, and radiographic and electrophysiological findings were more consistent with hemifacial seizures secondary to a brainstem lesion, rather than hemifacial spasms. It is important to distinguish the two entities, as misdiagnosis and inappropriate diagnostic or therapeutic measures may be taken inadvertently.

Acute Dystonia Following a Switch in Treatment from Atomoxetine to Low-dose Aripiprazole

The present report describes the cases of a 17-year-old male patient and a 13-year-old female patient who developed acute dystonia following the administration of low-dose aripiprazole (5 mg/day) after the cessation of atomoxetine treatment. Although aripiprazole-induced dystonia has been previously reported in the literature, it is rare, and most of these cases were associated with doses higher than 5 mg/day. Furthermore, both of the patients in the present study discontinued atomoxetine prior to the initiation of aripiprazole treatment; thus, this report also discussed the possible mechanisms underlying the manifestation of dystonia from the perspective of neurotransmitter activity.

Aripiprazole for Tourette's syndrome: a systematic review and meta-analysis

OBJECTIVE

To review the efficacy and safety of aripiprazole (ARI) for Tourette's syndrome (TS).

METHODS

This review included randomized controlled trials (RCTs) of children and adolescents (6-18 years) with TS comparing ARI monotherapy with another monotherapies in relation to clinical improvement and adverse events.

RESULTS

Six RCTs with a total of 528 subjects (ARI treatment group: n = 253; control group: n = 275) met the inclusion criteria. These included two RCTs (n = 255) that compared ARI monotherapy with tiapride (TIA). Tic symptoms control assessed by Yale Global Tic Severity Scale (Standard Mean Difference (SMD) = -0.38 (Confidence Interval (CI) = -1.32 to 0.56); I(2) = 90%, P = 0.42) revealed no significant differences between the two groups. Extrapyramidal symptoms were significantly different when ARI (1.5%) was compared with haloperidol (HAL) (43.5%). No significant group differences were found in the rates of nausea/vomiting, dizziness, and dry mouth between ARI and TIA (RR = 0.57 to 1.00 (95%CI = 0.14-4.20); I(2) = 0% to 69%, P = 0.35 to 1.00).

CONCLUSION

This review found that ARI has similar efficacy to TIA and HAL for TS, while extrapyramidal symptoms were significantly less with ARI than with HAL. ARI can be considered as an alternative treatment option for TS.

Tetrabenazine-induced oculogyric crisis - a rare complication in the treatment of Gilles de la Tourette syndrome

Tetrabenazine is used in the treatment of chorea, tardive dyskinesia, tics, and dystonia. It rarely causes acute eyeball dystonia and the description of this complication in Gilles de la Tourette syndrome is limited. We provide a description of an acute oculogyric crisis caused by tetrabenazine in a patient with severe tics. The patient had never developed acute dystonic reactions, although he was previously exposed to numerous dopamine receptor-blocking agents. After 8 days of therapy with tetrabenazine at a dose of 62.5 mg daily, the patient developed involuntary movement of the eyeballs. Withdrawal of tetrabenazine caused resolution of all symptoms after a week. The purpose of this description is to draw attention to the potential of tetrabenazine to induce acute oculogyric crisis as well as the difficulty of differentiating drug-induced dystonia from dystonic tics in patients with Gilles de la Tourette syndrome.

Incidence of Oculogyric Crisis and Long-Term Outcomes With Second-Generation Antipsychotics in a First-Episode Psychosis Program

Oculogyric crisis (OGC) is an often recurrent dystonic adverse effect of antipsychotic treatment characterized by a sustained fixed upward gaze lasting minutes to hours. The risk of OGC has not been established. We prospectively estimated the incidence rate of OGC in an early intervention service for psychosis and provided details regarding the antipsychotics implicated, clinical presentation, and long-term outcomes of OGC. The Nova Scotia Early Psychosis Program provides comprehensive, team-based care to youth and young adults with schizophrenia spectrum disorder. For 6 years (April 2008 to March 2014), 452 new patients were admitted to the program and participated in an individualized program of care. Eight patients (4 females; mean age, 19.8 years) developed recurrent episodes of OGC after 3 months to 2 years of treatment with 1 or more second-generation antipsychotics, yielding an incidence rate of 1.8% (95% confidence interval, 0.9%-3.4%). Risperidone or olanzapine (alone or in combination with a second antipsychotic) seemed causative in each case. Also implicated in the onset or recurrence of oculogyric episodes were ziprasidone, quetiapine, clozapine, aripiprazole, and the first-generation antipsychotic loxapine. Follow-up ranged between 2 and 7 years. Episodes stopped after switching antipsychotic treatment in 4 cases and after stopping antipsychotic treatment in 2 cases. In the other 2 cases, recurrences were ongoing at last follow-up 2 and 6 years after onset with antipsychotic treatment continuing. We observed a high rate of tardive-onset, recurrent, and potentially chronic ocular dystonias in patients with first-episode psychosis caused by the use of second-generation antipsychotics.

Clinical pharmacology of dopamine-modulating agents in Tourette's syndrome

Forty years of research and clinical practice have proved dopamine (DA) receptor antagonists to be effective agents in the treatment of Tourette's syndrome (TS), allowing a significant tic reduction of about 70%. Their main effect seems to be mediated by the blockade of the striatal DA-D2 receptors. Various typical and atypical agents are available and there is still discord between experts about which of them should be considered as first choice. In addition, there are suggestions to use DA receptor agonists such as pergolide or non-DA-modulating agents. The present chapter is focusing on the clinical pharmacology of DA-modulating agents in the treatment of TS. The introduction outlines their clinical relevance and touches on the hypotheses of the role of DA in the pathophysiology of TS. Subsequently, general information about the mechanisms of action and adverse effects are provided. The central part of the chapter forms a systematic review of all DA-modulating agents used in the treatment of TS, including an overview of studies on their effectiveness, and a critical discussion of their specific adverse effects. The present chapter closes with a summary of the body of evidence and a description of the resulting recommendations for the pharmacological treatment of TS.

Aripiprazole for the treatment of Tourette syndrome: a case series of 100 patients

OBJECTIVE

Aripiprazole is an atypical neuroleptic with agonistic and antagonistic dopaminergic and serotonergic effects. Because preliminary data obtained from uncontrolled studies suggest that aripiprazole may be effective in the treatment of tics, we performed a retrospective study with a large group of patients with Tourette syndrome.

METHODS

One hundred patients (78 men and 22 women; mean ± SD age, 27.1 years (± 11.5) years) who had been treated with daily doses of 5 to 45 mg (mean, 17.0 ± 9.6 mg) aripiprazole at our specialized Tourette syndrome outpatient clinic were included. Ninety-five patients with insufficient pretreatment (one or more neuroleptics) were switched to aripiprazole.

RESULTS

Eighty-two patients exhibited a considerable reduction in tic severity. In 48 patients, effective treatment lasted for more than 12 months. Five patients reported additional beneficial effects on behavioral comorbidities such as depression, anxiety, and autoaggression. Altogether, 31 patients (31%) dropped out of the treatment owing to inefficacy (n = 7), adverse effects (n = 15: drowsiness, agitation, weight gain, and sleep disturbances), both (n = 4) or other reasons (n = 5).

CONCLUSION

This is the largest case series on the treatment of tics with aripiprazole so far. Overall, our results corroborate previous data suggesting that aripiprazole is effective and safe in most patients. In particular, our data confirm effectiveness in adult patients and clarify that beneficial effects sustain. However, in contrast to previous data, in 1 of 3 of our highly selected patients, aripiprazole was ineffective or not well tolerated. Optimal dose seems to be individually different and may range from 5 to 45 mg.

Tolerability profile of aripiprazole in patients with Tourette syndrome

Over the last few years, aripiprazole has been proposed as a potentially useful medication for tics in patients with Tourette syndrome (TS). Aripiprazole has been associated with fewer adverse effects compared with other atypicals; however, little is known about its tolerability profile in the TS population. This study assessed the prevalence and characteristics of adverse effects resulting from the use of aripiprazole in a retrospective chart review of 29 patients with TS. Six patients (20.7%) discontinued aripiprazole because of the severity of specific adverse effects. The most commonly reported adverse effects were sedation (n = 9, 30%) and sleep problems (n = 5, 17%). In the majority of cases, adverse effects were not severe. There were no differences in demographic or clinical variables between the patients who did or did not experience adverse effects. The discontinuation rate of 20.7% suggests that aripiprazole is safe and reasonably well tolerated for use in TS. The prevalence of adverse effects appears to increase with treatment duration.

Update on the role of antipsychotics in the treatment of Tourette syndrome

Tourette syndrome (TS) is a neuropsychiatric disorder with typical onset in childhood and characterized by chronic occurrence of motor and vocal tics. The disorder can lead to serious impairments of both quality of life and psychosocial functioning, particularly for those individuals displaying complex tics. In such patients, drug treatment is recommended. The pathophysiology of TS is thought to involve a dysfunction of basal ganglia-related circuits and hyperactive dopaminergic innervations. Congruently, dopamine receptor antagonism of neuroleptics appears to be the most efficacious approach for pharmacological intervention. To assess the efficacy of the different neuroleptics available, a systematic, keyword-related search in PubMed (National Library of Medicine, Washington, DC) was undertaken. Much information on the use of antipsychotics in the treatment of TS is based on older data. Our objective was to give an update and therefore we focused on papers published in the last decade (between 2001 and 2011). Accordingly, the present review aims to summarize the current and evidence-based knowledge on the risk-benefit ratio of both first and second generation neuroleptics in TS.

[Aripiprazole use in children and adolescent psychiatric patients]

Aripiprazole inaugurates a new generation of antipsychotics called dopamine-serotonin system stabilizers. Its mechanism of action is different as aripiprazole is a partial dopamine D(2) and serotonin 5-HT(1A) receptor agonist and 5-HT(2A) receptor antagonist. Therefore, aripiprazole is thought to have an antagonistic action in the mesolimbic pathway but an agonistic action in the mesocortical pathway, tending to normalize the dopaminergic transmission regardless of the type of imbalance. Clinical trials involving children and adolescents have demonstrated the efficacy of aripiprazole in bipolar disorders, schizophrenia, mood disorders associated with pervasive developmental disorders, in tics and Tourette's. The most frequent side effects are extrapyramidal symptoms and sleepiness and are dose-dependent. Nevertheless, contrary to other second-generation antipsychotics available in France, it induces little weight gain, does not modify lipid and glucidic profiles, does not increase prolactin levels, or induce QTc lengthening. The main advantage of aripiprazole is its good safety profile, with different toxicity targets to other second-generation antipsychotics available in France. Aripiprazole appears to be an alternative for children and adolescents who are vulnerable to these side effects and are having trouble coping with them.

European clinical guidelines for Tourette syndrome and other tic disorders. Part II: pharmacological treatment

To develop a European guideline on pharmacologic treatment of Tourette syndrome (TS) the available literature was thoroughly screened and extensively discussed by a working group of the European Society for the Study of Tourette syndrome (ESSTS). Although there are many more studies on pharmacotherapy of TS than on behavioral treatment options, only a limited number of studies meets rigorous quality criteria. Therefore, we have devised a two-stage approach. First, we present the highest level of evidence by reporting the findings of existing Cochrane reviews in this field. Subsequently, we provide the first comprehensive overview of all reports on pharmacological treatment options for TS through a MEDLINE, PubMed, and EMBASE search for all studies that document the effect of pharmacological treatment of TS and other tic disorders between 1970 and November 2010. We present a summary of the current consensus on pharmacological treatment options for TS in Europe to guide the clinician in daily practice. This summary is, however, rather a status quo of a clinically helpful but merely low evidence guideline, mainly driven by expert experience and opinion, since rigorous experimental studies are scarce.

Treatment strategies for tics in Tourette syndrome

TOURETTE SYNDROME (TS) IS A CHRONIC NEURODEVELOPMENTAL DISORDER CHARACTERIZED BY TICS: repetitive, involuntary movements and vocalizations. These symptoms can have a significant impact on patients' daily functioning across many domains. Tics tend to be most severe in child and adolescent sufferers, so their presence has the potential to impact a period of life that is both critical for learning and is often associated with the experience of greater social tension and self-consciousness than adulthood. Furthermore, control over tics that lead to physical impairment or self-injurious behaviour is of vital importance in maintaining health and quality of life. There are numerous complicating factors in the prescription of treatment for tics, due to both the side effects associated with alleviating agents and patient characteristics, such as age and comorbid conditions. This review summarizes literature pertaining to the efficacy and safety of both traditionally prescribed and more modern medications. We also discuss the merits of behavioural and surgical techniques and highlight newer emerging treatments. Although treatment response is to some extent variable, there are a number of agents that are clearly useful as first-line treatments for TS. Other interventions may be of most benefit to patients exhibiting refractory tics or more specific symptom profiles.

[Aripiprazole - a medical treatment alternative for Tourette Syndrome in childhood and adolescence]

OBJECTIVE

We report a case-series of seven patients with a medical history of at least two years of tic disorder treated with the partial dopamine agonist aripiprazole to illustrate its efficacy as a treatment alternative for motor and vocal tics in children and adolescents.

METHOD

A case series of five patients with Tourette Syndrome (TS) and two with chronic motor tic disorder (age range 8; 7-18; 1 year), the majority of whom had been refractory to treatment with other neuroleptics or had ceased treatment due to intolerable side effects, were treated for eight weeks with aripiprazole. Before and after treatment, parents rated the severity of motor and vocal tic symptoms on the Yale Tourette Syndrome Checklist.

RESULTS

Within eight weeks mean motor tic symptoms decreased by 66% and mean vocal tic symptoms decreased by 26%. Mean effective dosage was 14.3 mg/day (min. 5 mg, max. 30 mg). Symptoms of comorbid ADHD or Obsessive Compulsive Disorder were not significantly influenced. During medication only mild side effects were observed, e.g., abdominal pain, fatigue and increased emotional sensitivity. No patient dropped out of treatment due to side effects.

CONCLUSIONS

Aripiprazole may be an effective pharmacologic treatment alternative for individuals with chronic motor tic disorder and TS. It induces quick, significant and sustained effects with few generally mild and transient side effects, if anything. Its effectiveness, especially relative to comorbidities, should be verified in double-blind, placebo-controlled studies.

Emerging role of aripiprazole for treatment of irritability associated with autistic disorder in children and adolescents

Autistic disorder is a largely misunderstood and difficult to treat neurodevelopmental disorder. Three core domains of functioning are affected by autistic disorder, ie, socialization, communication, and behavior. Signs of autistic disorder may be present early, but are frequently overlooked, resulting in a delay in its diagnosis and a subsequent delay in treatment. No one definitive therapy is available, and treatment consists of early educational and behavioral interventions, as well as drug therapy. Atypical antipsychotics have often been used in the treatment of autistic disorder to target irritability, aggression, and self-injurious behavior, all of which can interfere with other aspects of treatment. One atypical antipsychotic, aripiprazole, has recently been approved for treatment of irritability associated with autistic disorder. Based on the results from two randomized, controlled trials, with efficacy data from nearly 300 patients, treatment with aripiprazole was associated with reductions in irritability, global improvements in behavior, and improvements in quality of life from both the patient and caregiver perspectives. Dosage of aripiprazole ranged from 5 mg to 15 mg per day. Aripiprazole was well tolerated during clinical trials, with most adverse events considered mild or moderate. Clinically relevant weight gain occurred in about 30% of patients given aripiprazole, although when compared with other atypical antipsychotics, aripiprazole appears to have fewer metabolic effects and a lower risk of weight gain. However, pediatric patients taking any atypical antipsychotic should be carefully monitored for potential adverse events, because the long-term effects of antipsychotic therapy in this population are not well known. When used appropriately, aripiprazole has the potential to be an effective treatment for children with autistic disorder to improve irritability and aggressive behavior and improve quality of life.

Effectiveness and tolerability of aripiprazole in children and adolescents with Tourette's disorder: a pilot study in China

OBJECTIVE

The primary aim of the study was to evaluate the effectiveness and tolerability of aripiprazole on motor and vocal tics in children and adolescents with Tourette's disorder (TD). The secondary aim was to assess the response of TD-associated behaviors to aripiprazole exposure.

METHODS

This was an 8-week, open-label trial with flexible dosing strategy of aripiprazole in children and adolescents with TD. A total of 72 patients, aged 6-18 years, participated in the 8-week trial. The Yale Global Tic Severity Scale (YGTSS), the Clinical Global Impressions-Tics (CGI-Tics), and the Child Behavior Checklist (CBCL) were compared at the baseline, weeks 2 and 4, and end point. The side effects of aripiprazole, electrocardiogram (ECG), and body mass index (BMI) were evaluated.

RESULTS

Over the 8-week trial, aripiprazole administration was associated with a significant decrease in total tic severity as measured by the YGTSS (50.3% reduction by week 8). The mean scores of motor tic in the YGTSS were 17.42 +/- 4.83, 12.93 +/- 3.76, 8.39 +/- 3.70, and 6.75 +/- 3.95 at baseline, weeks 2 and 4, and end point. A significant decrease in the scores was observed in week 2 compared to the baseline, and the scores continued to decrease for the remainder of the study period (degrees of freedom [df ] = 3, F = 96.02, p = 0.000). The mean phonic tic scores were 12.71 +/- 4.60, 8.53 +/- 3.26, 6.10 +/- 2.50, and 3.63 +/- 2.20 at baseline, weeks 2 and 4, and end point, respectively. A significant change was observed during week 2 compared to the baseline, and this change continued for the rest of the study period (df = 3, F = 95.16, p = 0.000). Significant improvement was also observed according to the CGI-Tics severity. The mean CGI-Tics severity score was 4.77 +/- 1.69 at baseline and decreased to 2.20 +/- 1.39 at end point (t = 10.70, p = 0.000). A significant reduction of behavior symptoms was noticed according to the CBCL and its subscales between baseline and end point. The majority of subjects tolerated aripiprazole well. The extrapyramidal symptoms (EPS) during this study were negligible. In all 21 (29.2%) of the 72 participants complained of nausea and 19 (26.4%) of them reported sedation. There was no significant difference of BMI between the two phases (df = 64, t = -0.94, p = 0.352). There were no significant changes in laboratory results. ECG monitoring revealed no significant impact on cardiac conduction by aripiprazol.

CONCLUSION

In this preliminary open-label trial, aripiprazole showed effectiveness in treating tic symptoms without causing significant weight gain or other serious side effects. Aripiprazole could be an option for TD cases that do not respond to conventional therapies. Further controlled, double-blind studies are warranted.

Ocular adverse effects of common psychotropic agents: a review

All psychotropic medications have the potential to induce numerous and diverse unwanted ocular effects. Visual adverse effects can be divided into seven major categories: eyelid and keratoconjunctival disorders; uveal tract disorders; accommodation interference; angle-closure glaucoma; cataract/pigmentary deposits in the lens and cornea; retinopathy; and other disorders. The disorders of the eyelid and of the keratoconjunctiva are mainly related to phenothiazines and lithium. Chlorpromazine, at high dosages, can commonly cause abnormal pigmentation of the eyelids, interpalpebral conjunctiva and cornea. It can also cause a more worrisome but rarer visual impairment, namely corneal oedema. Lithium can rarely lead to a bothersome eye irritation by affecting sodium transport. Uveal tract problems are mainly associated with tricyclic antidepressants (TCAs), typical antipsychotics, topiramate and selective serotonin reuptake inhibitors (SSRIs). TCAs, typical antipsychotics and SSRIs can all cause mydriasis that is often transient and with no major consequences, but that can promote closure of angles in susceptible patients. Topiramate has been frequently associated with a number of significant ocular symptoms including acquired myopia and angle-closure glaucoma. Problems with accommodation are related to TCAs and to low-potency antipsychotics. TCAs cause transient blurred vision in up to one-third of patients. Angle-closure glaucoma is a serious condition that has been mainly associated with TCAs, low-potency antipsychotics, topiramate and, to a lesser extent, SSRIs. When patients with narrow angles are given TCAs, they all appear to experience induction of glaucomatous attacks. Antipsychotics and SSRIs may lead to an added risk of developing angle-closure glaucoma, but only in predisposed eyes. Topiramate can lead to an allergic-type reaction whereby structures of the lens and ciliary body are displaced, which results in angle-closure glaucoma. Cataractous changes can result from antipsychotics, mainly from high dosages of chlorpromazine or thioridazine. These two drugs, when used at high dosages and for prolonged periods, frequently cause lenticular opacifications. Retinopathy has been shown to be related to high dosages of typical antipsychotics, mainly chlorpromazine and thioridazine. The frequency of occurrence of retinal effects seems to be proportional to the total amount of drug used over a long period of time. Other visual problems of special concern are the ocular dystonias, other eye movement disorders, and decreased ability to perceive colours and to discriminate contrast. Ocular dystonias can occur with antipsychotics (especially high-potency ones), carbamazepine (especially in polytherapy), topiramate and, rarely, with SSRIs. Disturbance in various eye movements is frequently seen with benzodiazepines, antiepileptic drugs and lithium. Impairment in the perception of colours and the discrimination of contrasts has been shown to occur not uncommonly with carbamazepine and lorazepam. Thus, typical antipsychotics, TCAs, lithium, benzodiazepines, carbamazepine, topiramate and SSRIs appear to produce most of the currently recognized ocular problems. Psychiatrists, ophthalmologists and patients need to be aware of and prepared for any medication-induced adverse effect. Early prevention and intervention can avoid most of the serious and potentially irreversible ocular toxicities.

Aripiprazole for the treatment of adolescent Tourette's syndrome: a case report

Gilles de la Tourette syndrome (GTS) is a neuropsychiatric, lifelong disorder with onset in childhood. The essential features of this disorder are multiple motor tics and one or more vocalizations. The neurochemical pathophysiology of GTS involves an unknown abnormality in the central dopaminergic system. Atypical antipsychotics, such as aripiprazole, serve as a new therapeutic option for GTS. The authors describe a unique case of Tourette's syndrome (TS) in an adolescent in which aripiprazole resolved the patient's symptoms. A 17-year-old, 5'11'' tall, African American male weighing 220 lbs was diagnosed with TS at 9 years old. By age 16, the patient developed prominent symptoms of intermitted eye blinking, forehead raising, finger snapping, heavy breathing, and head bobbing. Clonidine, in addition to homeopathic remedies (N-acetylcholine and alpha lipoic acid), was administered to the patient without significant diminution of symptoms. Later, aripiprazole was initiated at 5 mg/d. As a result, noticeable symptomatic improvement occurred within 48 hours. Aripiprazole was titrated over the next 4 weeks to 6.5 mg/d, with significant results. Over the next 6 months, aripiprazole was titrated again to 10 mg/d with additional symptom reduction. This case illustrates a patient who responded to aripiprazole with no reported adverse effects, when standard therapy failed to improve symptoms.

Aripiprazole in the pharmacotherapy of Gilles de la Tourette syndrome in adult patients

Despite the ongoing development of neuroleptics, typical or first-generation neuroleptics are still considered as the first choice in the treatment of Gilles de la Tourette syndrome (GTS). In many European countries, tiapride is the first line of treatment favoured in most cases, while risperidone, pimozide and haloperidol are listed as second choice. Unfortunately, antipsychotics often show tachyphylactic effects in the treatment of GTS so that a switch to another neuroleptic agent becomes inevitable. Thus it is important to ensure a wide selection of different drugs is available. Another promising candidate in the treatment of tics may be aripiprazole, a D(2)-receptor partial agonist. We present the retrospective analysis of 10 clinical cases of adult patients from the tic clinics in Aachen (Germany) and Zurich (Switzerland) who were treated with aripiprazole. Tics and disturbances were assessed using the Yale Global Tic Severity Scale (YGTSS). All YGTSS-subscores, with the exception of the complexity of vocal tics, improved significantly. The data includes three cases with long-term intake for at least 18 months. During this period, no tachyphylactic effect was visible. A double-blind trial against placebo or other neuroleptics is advisable to verify the efficacy of aripiprazole in the pharmacotherapy of GTS.

Movement disorders associated with aripiprazole use: a case series

Aripiprazole is an atypical antipsychotic that is a partial agonist at the D2 and 5HT1a receptors and an antagonist at 5HT2a receptors. Despite previous hypotheses that it would be less likely to cause movement disorders, recent reports suggest it actually may be more likely to cause movement disorders than other atypical antipsychotics. This case series illustrates the variety of movement disorders associated with aripiprazole use at three movement disorder clinics. It also suggests that aripiprazole be used with caution in patients with a prior history of dystonia, parkinsonism, or previous tardive dyskinesia.

Aripiprazole in children and adolescents with Tourette's disorder: an open-label safety and tolerability study

OBJECTIVE

The aim of this study was to conduct a prospective safety and tolerability study of aripiprazole for the treatment of tics in children and adolescents with Tourette's disorder (TD).

METHOD

Eleven subjects (10 males) with TD (age 9-19 years, mean 13.36, standard deviation [SD] 3.33) who did not respond or were unable to tolerate previous tic medication were treated with aripiprazole in an open-label, flexible-dosing study over 10 weeks. Tic severity was rated using the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impressions Scale for tics (CGI-Tics) at baseline and at follow-up.

RESULTS

The mean (+/-SD) daily dose for aripiprazole was 4.5 +/- 3.0 mg. Mean (+/-SD) YGTSS Global Severity scores reduced from 61.82 +/- 13.49 at baseline to 33.73 +/- 15.18 at end point; mean YGTSS total tic scores reduced from 28.18 +/- 7.74 at baseline to 16.73 +/- 7.54 at end point. Mean (+/-SD) CGI-Tic severity scores reduced from 4.45 +/- 0.52 (moderate-marked) at baseline to 3.18 +/- 0.60 (mild) at end point. On the CGI-Tic improvement scale, 10 (91%) subjects achieved 1 ("very much improved") or 2 ("much improved") at end point. Most common adverse effects included appetite increase and weight gain in 5 subjects, mild extrapyramidal effects in 7 subjects, and headaches and tiredness/fatigue in 7 subjects; 1 subject experienced akathisia and muscle cramps.

CONCLUSION

Aripiprazole appears to be a safe and tolerable treatment in children and adolescents with TD that appears to reduce tics; it should be further investigated as a treatment option in controlled trials.

Efficacy and safety of aripiprazole in the treatment of bipolar disorder: a systematic review

BACKGROUND

The current article is a systematic review concerning the efficacy and safety of aripiprazole in the treatment of bipolar disorder.

METHODS

A systematic Medline and repositories search concerning the usefulness of aripiprazole in bipolar disorder was performed, with the combination of the words 'aripiprazole' and 'bipolar'.

RESULTS

The search returned 184 articles and was last updated on 15 April 2009. An additional search included repositories of clinical trials and previous systematic reviews specifically in order to trace unpublished trials. There were seven placebo-controlled randomised controlled trials (RCTs), six with comparator studies and one with add-on studies. They assessed the usefulness of aripiprazole in acute mania, acute bipolar depression and during the maintenance phase in comparison to placebo, lithium or haloperidol.

CONCLUSION

Aripiprazole appears effective for the treatment and prophylaxis against mania. The data on bipolar depression are so far negative, however there is a need for further study at lower dosages. The most frequent adverse effects are extrapyramidal signs and symptoms, especially akathisia, without any significant weight gain, hyperprolactinaemia or laboratory test changes.

New hypotheses about postural control support the notion that all dystonias are manifestations of excessive brain postural function

This paper postulates that all forms of the neurological movement disorder, dystonia, can be argued to reflect excessive function of one or more components of the brain postural system. This is based on four central arguments. First, because some forms of postural control are already known to be dynamic, rather than static, it is suggested that hyperkinetic dystonias reflect excessive function of dynamic postures, rather than abnormal movements. Second, the range of functional roles served by the postural system is hypothesized to include direct control of movement, suggesting a postural basis for task-specific dystonias. Third, by defining posture as a neural system that maintains body stabilization, it can be shown that the range of mechanical means of implementing stabilization, including co-contraction of antagonistic muscles, matches the range of presentations of dystonia. Fourth, it is shown that the above premises are able to account for previously unexplained observations in dystonia. Based on the inhibitory influence that stabilizing mechanisms exert on movement, it is suggested that the broad functional role that is here referred to as posture may be the function served by the indirect pathway of the basal ganglia. Specifically, it is proposed that this pathway centrally coordinates function of the distributed network of brain regions controlling posture and, in conjunction with the direct pathway, coordinates posture and movement.