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Atypical Antipsychotics for Tourette Syndrome
Pierce, A., Cavanna, A. E., and Rickards, H. E.
Implications for Research
The aim of this Cochrane review is to evaluate the efficacy and safety of
Three randomised controlled trials (two comparing risperidone and one
There are several recommendations that can be made as a result of this
atypical antipsychotics compared with placebo in treating tics in patients
comparing ziprasidone with placebo) were identified. Methodological
review. In particular future trials involving Tourette syndrome patients
quality was rated as ‘unclear’. Studies used different measurement
heterogeneity made meta-analysis inappropriate. Risperidone was
1. Involve larger numbers of patients to judge the efficacy and safety of
superior to placebo in one trial although the 95% confidence intervals
atypical antipsychotics in the treatment of Tourette syndrome.
Neuroleptic drugs with potent D-2 receptor blocking properties have
were very large. Two trials showed no statistical difference between
2. Include valid sample size power calculations thereby reducing the
been the traditional treatment for tics in patients with Tourette syndrome.
Risperidone and ziprasidone against placebo. Risperidone caused
However these medications have several side effects which limit their
some extrapyramidal side-effects as well as weight gain.
3. Include a placebo controlled group for all treatment efficacy trials.
use, including extrapyramidal, behavioural and metabolic problems.
4. Follow CONSORT guidelines to improve the reporting standards
Over the last few years a number of studies have investigated the use of
5. Aim to enlist uniform cohorts of patients with Tourette syndrome.
atypical antipsychotic treatments in Tourette syndrome. The true
6. Be of sufficient duration to assess the long term effects of the illness
benefits and risks associated with the atypical antipsychotics treatments
especially weight gain and the resultant physical health issues and
7. The Yale Global Tic Symptom Scale (YGTSS) should be used to
assess the primary outcome measure (tic severity) and a disease-
specific patient-reported QOL scale should be used to assess the
We cross referenced atypical antipsychotics - risperidone, olanzapine,
secondary outcome measure (health-related quality of life). Side effects
amisulpiride, quetiapine, loxapine, ziprasidone, clotiapine,
should be quantified with the Extrapyramidal Symptom Rating Scale
aripiprazole, remoxipride, sertindole, zotepine, sulpiride - and their
proprietary names with ‘Tourette Syndrome’ and it’s derivations as
8. Explicitly look for, analyse and report on data related to the
MeSH headings and as text words and searched the Cochrane
Movement Disorder Group Trials Register, Cochrane Central Register of
Dion Y. Annable L. Sandor P. Chouinard G. Risperidone in the treatment of Tourette syndrome: a double-blind, placebo-controlled trial.
9. Report all data in a consistent manner, including mean and standard
Journal of Clinical Psychopharmacology. 2002 Feb.; 22(1):31-9.
Controlled Trials (CENTRAL) (The Cochrane Library 2010, issue 3),
Sallee FR, Kurlan R, Goetz CG, Singer H, Scahill L, Law G, Dittman VM, Chapell PB. Ziprasidone Treatment of Children and Adolescents with
MEDLINE (1950-2010), EMBASE (1980-2010), PsycINFO (1987-2010)
J. Am. Acad. Child Adolesc. Psychiatry Mar 2000;39(3):292-9.
10. Report data at the end of the first arm of the trial if it is a crossover
Scahill L. Leckman JF. Schultz RT. Katsovich L. Peterson BS. A placebo-controlled trial of risperidone in Tourette syndrome.
Neurology. 2003 Apr 8.;60(7):1130-5.
11. Use a parallel design and not rely on cross over trial designs.
Grey literature, reference lists, hand searching, clinical trials websites
12. The analysis of the data should be in a true ‘Intention to treat’
and pharmaceutical company sites were also used. All randomized,
principle and the change in outcomes must be compared statistically
It is difficult to draw clear conclusions from the identified trials in the
controlled, double blind studies comparing atypical antipsychotics to
review as evidence for efficacy and safety of atypical antipsychotics is
placebo for the treatment of tics in Tourette syndrome were considered
13. Further analyse dropout information using the appropriate statistical
limited. There is evidence suggesting potential efficacy of risperidone,
which prompts further investigations on atypical antipsychotics inTourette syndrome populations. Trials with longer duration and larger
Declaration of Interests
Data Collection and Analysis
groups are needed to investigate the safety and efficacy of the atypicalantipsychotics
Data were extracted independently by two authors onto standardized
CONSORT reporting guidelines, the Yale Global Tic Symptom Scale
forms. Data were analysed using the random effects method to
(YGTSS) to assess the primary outcome measure (tic severity) and
establish the effect measure of mean difference. Review Manager
disease- specific patient-reported quality of life (QOL) instruments, such
Anita Pierce: No declaration of interests
as the GTS-QOL, to assess the secondary outcome measure (health-
Andrea E. Cavanna: No declaration of interests
Collaboration) was used to manage and analyse the data.
related quality of life). Side effects should be quantified with the
Hugh E. Rickards: No declaration of interests
Extrapyramidal Symptom Rating Scale (ESRS) as well as objectivemeasures focusing on metabolic syndrome and weight gain.
, Acute Care Consultant Psychiatrist, Ablett Psychiatric Unit, Betsi Cadwaladr University Health Board, North Wales, UK.Andrea E. Cavanna
, Consultant in Behavioural Neurology, Department of Neuropsychiatry, University of Birmingham, and BSMHFT, Birmingham, UK; Department of Neuropsychiatry, Institute of Neurology and UCL, London, UK.Hugh E. Rickards
, Consultant Neuro-psychiatrist, Department of Neuropsychiatry, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK.
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