Pringsheim Tamara, Steeves Thomas
Clinical Assistant Professor, Department of Clinical Neurosciences and Pediatrics, University of Calgary, Alberta Children's Hospital, C4-431, 2888 Shaganappi Trail NW, Calgary, Alberta, Canada, AB T3B 6A8.
Cochrane Database Syst Rev. 2011 Apr 13(4):CD007990. doi: 10.1002/14651858.CD007990.pub2.
Attention Deficit Hyperactivity Disorder (ADHD) is the most prevalent of the comorbid psychiatric disorders that complicate tic disorders. Medications commonly used to treat ADHD symptoms include the stimulants methylphenidate and amphetamine; nonstimulants, such as atomoxetine; tricyclic antidepressants; and alpha agonists. Due to the impact of ADHD symptoms on the child with tic disorder, treatment of ADHD is often of greater priority than the medical management of tics. However, for many decades clinicians have been reluctant to use stimulants to treat children with ADHD and tics for fear of worsening their tics.
To assess the effects of pharmacological treatments for ADHD on ADHD symptoms and tic severity in children with ADHD and comorbid tic disorders.
We searched CENTRAL (The Cochrane Library 2009, Issue 4), MEDLINE (1950 to July 2009), EMBASE (1980 to July 2009), CINAHL (1982 to July 2009), PsycINFO (1806 to July Week 4 2009) and BIOSIS Previews (1985 to July 2009). Dissertation Abstracts (searched via Dissertaation Express), and the metaRegister of Controlled Trials were searched (30 July 2009).
We included randomized, double-blind, controlled trials of any pharmacological treatment for ADHD used specifically in children with comorbid tic disorders. We included both parallel group and cross-over study designs.
Two authors independently extracted data using standardized forms.
We included a total of eight randomized controlled studies in the review but were unable to combine any of these in meta-analysis. Several of the trials assessed multiple agents. Medications assessed included methylphenidate, clonidine, desipramine, dextroamphetamine, guanfacine, atomoxetine, and deprenyl. All treatments, with the exception of deprenyl, were efficacious in treating symptoms of ADHD. Tic symptoms improved in children treated with guanfacine, desipramine, methylphenidate, clonidine, and the combination of methylphenidate and clonidine. Fear of worsening tics limited dose increases of methylphenidate in one study. High dose dextroamphetamine appeared to worsen tics in one study, although the length of this study was limited.
AUTHORS' CONCLUSIONS: Methylphenidate, clonidine, guanfacine, desipramine and atomoxetine appear to reduce ADHD symptoms in children with tics. Although stimulants have not been shown to worsen tics in most people with tic disorders, they may nonetheless exacerbate tics in individual cases. In these instances, treatment with alpha agonists or atomoxetine may be an alternative. Although there is evidence that desipramine is effective for both tics and ADHD in children, safety concerns will likely continue to limit its use in this population.
注意缺陷多动障碍（ADHD）是使抽动障碍复杂化的最常见的共病精神障碍。常用于治疗ADHD症状的药物包括兴奋剂哌甲酯和苯丙胺；非兴奋剂，如托莫西汀；三环类抗抑郁药；以及α激动剂。由于ADHD症状对患有抽动障碍的儿童有影响，ADHD的治疗通常比抽动障碍的药物治疗更为优先。然而，几十年来，临床医生一直不愿使用兴奋剂来治疗患有ADHD和抽动障碍的儿童，因为担心会加重他们的抽动症状。
评估药物治疗ADHD对患有ADHD和共病抽动障碍的儿童的ADHD症状和抽动严重程度的影响。
我们检索了考克兰中心对照临床试验注册库（The Cochrane Library 2009年第4期）、医学期刊数据库（MEDLINE，1950年至2009年7月）、荷兰医学文摘数据库（EMBASE，1980年至2009年7月）、护理学与健康领域数据库（CINAHL，1982年至2009年7月）、心理学文摘数据库（PsycINFO，1806年至2009年第4周）以及生物学文摘数据库（BIOSIS Previews，1985年至2009年7月）。通过学位论文数据库（Dissertation Express）检索了学位论文摘要，并检索了对照试验的元注册库（2009年7月30日）。
我们纳入了专门用于患有共病抽动障碍儿童的任何ADHD药物治疗的随机、双盲、对照试验。我们纳入了平行组和交叉研究设计。
两位作者使用标准化表格独立提取数据。
我们在综述中总共纳入了八项随机对照研究，但无法将其中任何一项纳入荟萃分析。几项试验评估了多种药物。评估的药物包括哌甲酯、可乐定、去甲丙咪嗪、右旋苯丙胺、胍法辛、托莫西汀和司来吉兰。除司来吉兰外，所有治疗方法在治疗ADHD症状方面均有效。用胍法辛、去甲丙咪嗪、哌甲酯、可乐定以及哌甲酯和可乐定联合治疗的儿童抽动症状有所改善。在一项研究中，对抽动加重的担忧限制了哌甲酯剂量的增加。在一项研究中，高剂量的右旋苯丙胺似乎使抽动症状恶化，尽管该研究的时间有限。
哌甲酯、可乐定、胍法辛、去甲丙咪嗪和托莫西汀似乎能减轻患有抽动障碍儿童的ADHD症状。虽然在大多数抽动障碍患者中未显示兴奋剂会加重抽动症状，但在个别情况下它们可能会加剧抽动。在这些情况下，使用α激动剂或托莫西汀治疗可能是一种替代方法。虽然有证据表明去甲丙咪嗪对儿童的抽动和ADHD均有效，但安全问题可能会继续限制其在该人群中的使用。
