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Let’s start our USMLE Review with Drugs of Choice from the Gold Standard USMLE Step 2 Audio Review program.
Play USMLE Audio MP3 20 08 Drugs of Choice Tourette Syndrome Below
What is the genetically transmitted neuropsychiatric disorder that consists of a number of different tic disorders, obsessive-compulsive symptoms, attention disorders, and other behaviors linked to problems with impulse control, such as uncontrollable cursing?
- This is TS- Tourette’s Syndrome.
How is Tourette’s Syndrome transmitted? It is primarily autosomal dominant, however, it is influenced by what?
- Sex-linked genes and it displays, in terms of penetrance, variable penetrance.
The majority of individuals with Tourette’s Syndrome have what level of disease?
- Mild disease that probably does not require medical intervention, however, for those whose symptoms are severe, drug therapy is required to give them a quality of life that is acceptable.
Is there good scientific evidence for supporting the hypothesis that some drugs may be better for motor tics and some might be better for vocal tics?
- No, not at this time.
What is the best known Tourette’s Syndrome medication that is, however, avoided by some experts, because of its possibility for serious side effects?
- This is Haloperidol.
Trade name for Haloperidol?
What class of drug is Haloperidol (trade name Haldol)?
- It is a neuroleptic.
What is its primary site or mechanism of action?
- To block dopamine receptors.
What chemical class of neuroleptic drugs is Haloperidol (trade name Haldol) in?
- It is a butyrophenone.
In terms of potency, where does Haloperidol (trade name Haldol) fall?
- It is a high-potency neuroleptic.
And because it is a high-potency neuroleptic, what very serious side effect is a possibility?
- Tardive dyskinesia.
And how does this risk of developing tardive dyskinesia especially relate to the treatment of Tourette’s Syndrome?
- Treatment must be chronic, long-term, and the longer that a high-potency neuroleptic is given to the patient, the greater the risk for tardive dyskinesia. Just a little editorial note here, which I hardly ever do: If you have never seen a patient with tardive dyskinesia, please go do so before prescribing neuroleptics. I have seen one in a psychiatric hospital, and here’s what I observed. She was sitting there, looking at me quietly, smiling a little bit. I spoke to her, I asked her a question. She attempted to respond. In attempting to respond, she threw her head back violently, her mouth opened wider than I thought possible, and her tongue wagged around violently while she made inarticulate grunts. After about, well, it seemed like an hour, but it probably wasn’t longer than 30 to 60 seconds, she brought her head back, closed her mouth, and looked at me as if she thought she had answered me.
What is probably the drug of choice as a first-choice drug for the treatment of Tourette’s Syndrome?
And what is the trade name?
What is Clonidine less effective at than Haloperidol?
- Suppressing the tics.
However, it does have beneficial action on 5 areas of behavior in the Tourette’s Syndrome patient. What are they?
- It helps with attention problems, it helps the patient control impulsivity, it helps them avoid temper outbursts, it lowers their anxiety, and it decreases oppositional types of behavior.
In what patient population is Clonidine (trade name Catapres) most appropriate for, as a first-line agent?
- Children with Tourette’s Syndrome.
What is the main side effect with Clonidine (trade name Catapres)?
- Some sedation over the first days to weeks.
What is a rare, more serious side effect with Clonidine (trade name Catapres)?
- Serious hypotension.
How can this usually be avoided?
- By starting at a low dose, and then bringing it up slowly.
What are the 2 main routes of administration for Clonidine (trade name Catapres)?
- Either oral or a transdermal patch.
If Clonidine (trade name Catapres) is not effective, and if the physician wishes to avoid the use of Haloperidol (trade name Haldol), what are 3 other traditional neuroleptics which are likely to work as well as Haloperidol, with possibly less chance of side effect?
- Pimozide, Fluphenazine, or Thiothixene.
What is the trade name for Pimozide?
And what is the trade name for Fluphenazine?
And the trade name for Thiothixene?
Which of these is closest to Haloperidol (trade name Haldol) in terms of being a potent dopamine receptor antagonist?
- Pimozide (trade name Orap).
What type of neuroleptic is Fluphenazine (trade name Prolixin)?
- It is a phenothiazine.
And what type of neuroleptic drug is Thiothixene?
- It is a thioxanthene.
What is the newly introduced so-called “novel” neuroleptic agent, which may have (although it isn’t proven yet) lower risk of causing tardive dyskinesia, and which is sometimes effective for Tourette’s Syndrome?
- This is Risperidone.
And the trade name?
And what chemical class of neuroleptic drug is Risperidone (trade name Risperidol)?
- It is a benzisoxazole.
Finally, what is the anti-epileptic drug that sometimes helps in controlling mild tics and which can be used in combination with the other medications? This is Clonazepam.
And what kind of drug generally is Clonazepam (trade name Klonopin)?
- This is a benzodiazepine antiepileptic agent.
What is the main disadvantage to using Clonazepam (trade name Klonopin)?
- It may cause addiction.
Again, however, what is the first-line drug of choice for treating Tourette’s Syndrome?
And what general class of drug is Clonidine (trade name Catapres)?
- It is a centrally acting adrenergic drug.
In terms of receptor activity, what type of drug specifically is Clonidine (trade name Catapres)?
- It is an alpha-2 agonist, which diminishes what flow in the central nervous system? It diminishes central adrenergic outflow.
What is Clonidine (trade name Catapres) used primarily for?
- For mild to moderate hypertension.
And in particular, for what class of patient? Because Clonidine (trade name Catapres) does not compromise renal function, it is useful in hypertensive patients who have renal disease.
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