Bloch Michael H, Panza Kaitlyn E, Landeros-Weisenberger Angeli, Leckman James F
J Am Acad Child Adolesc Psychiatry. 2009 Sep;48(9):884-893. doi: 10.1097/CHI.0b013e3181b26e9f.
The Food and Drug Administration currently requires the package inserts of most psychostimulant medications to list the presence of a tic disorder as a contraindication to their use. Approximately half of children with Tourette's syndrome experience comorbid attention-deficit/hyperactivity disorder (ADHD). We sought to determine the relative efficacy of different medications in treating ADHD and tic symptoms in children with both Tourette's syndrome and ADHD.
We conducted a PubMed search to identify all double-blind, randomized, placebo-controlled trials examining the efficacy of medications in the treatment of ADHD in the children with comorbid tics. We used a random effects meta-analysis with standardized mean difference as our primary outcome to estimate the effect size of pharmaceutical agents in the treatment of ADHD symptoms and tics.
Our meta-analysis included nine studies involving 477 subjects. We assessed the efficacy of six medications-dextroamphetamine, methylphenidate, alpha-2 agonists (clonidine and guanfacine), desipramine, atomoxetine, and deprenyl. Methylphenidate, alpha-2 agonists, desipramine, and atomoxetine demonstrated efficacy in improving ADHD symptoms in children with comorbid tics. Alpha-2 agonists and atomoxetine significantly improved comorbid tic symptoms. Although there was evidence that supratherapeutic doses of dextroamphetamine worsens tics, there was no evidence that methylphenidate worsened tic severity in the short term.
Methylphenidate seems to offer the greatest and most immediate improvement of ADHD symptoms and does not seem to worsen tic symptoms. Alpha-2 agonists offer the best combined improvement in both tic and ADHD symptoms. Atomoxetine and desipramine offer additional evidence-based treatments of ADHD in children with comorbid tics. Supratherapeutic doses of dextroamphetamine should be avoided.
美国食品药品监督管理局目前要求大多数精神刺激药物的药品说明书将抽动障碍的存在列为使用这些药物的禁忌症。约一半的抽动秽语综合征患儿同时患有注意力缺陷多动障碍（ADHD）。我们试图确定不同药物在治疗同时患有抽动秽语综合征和ADHD的儿童的ADHD及抽动症状方面的相对疗效。
我们在PubMed上进行检索，以识别所有双盲、随机、安慰剂对照试验，这些试验检验了药物在治疗合并抽动症状的儿童ADHD方面的疗效。我们采用随机效应荟萃分析，以标准化均数差作为主要结局指标，来估计药物制剂在治疗ADHD症状和抽动方面的效应大小。
我们的荟萃分析纳入了9项研究，涉及477名受试者。我们评估了6种药物的疗效，即右旋苯丙胺、哌醋甲酯、α-2激动剂（可乐定和胍法辛）、地昔帕明、托莫西汀和司来吉兰。哌醋甲酯、α-2激动剂、地昔帕明和托莫西汀在改善合并抽动症状的儿童的ADHD症状方面显示出疗效。α-2激动剂和托莫西汀显著改善了合并的抽动症状。虽然有证据表明超治疗剂量的右旋苯丙胺会使抽动加重，但没有证据表明哌醋甲酯在短期内会加重抽动严重程度。
哌醋甲酯似乎能最显著、最迅速地改善ADHD症状，且似乎不会加重抽动症状。α-2激动剂在抽动和ADHD症状的综合改善方面效果最佳。托莫西汀和地昔帕明为合并抽动症状的儿童ADHD提供了更多基于证据的治疗方法。应避免使用超治疗剂量的右旋苯丙胺。
