Refractoriness to pharmacological treatment for tics: A multicentre European audit
Recently, a consensus definition of treatment responsiveness for obsessive compulsive disorder has been reached through Delphi survey methodology, showing great potential for practical application in clinical care [1] A standardized definition of refractoriness to pharmacological treatment of tics in TD (chronic tic disorders including Tourette Syndrome) would aid decisions on drug switch, psychological treatment or access to invasive treatments like functional surgery [2,3] We conducted a European audit survey in order to: i) explore the main features that would define refractoriness of tics to pharmacological treatment, and ii) assess how consistently these features are taken into account in routine clinical practice. Itemsdefining treatment refractoriness in TDwas discussedwithin a panel of seven expert clinicians (panel clinicians) across different European countries. All panel members were invited to rate each item according to whether the domain measured was 'essential' or not for the definition of refractoriness. Only those items for which a unanimous judgement of 'essential'was reachedwere then considered for the audit survey. This procedure yielded the following list of 'essential' items: duration of treatment (weeks) dichotomous judgement of improvement of tic severity (improved/not improved) documented change of the Yale Global Tic Severity Scale (YGTSS) 0 50 severity score; reason for themaximum dose reached; number of single doses missed on average over a 10 day period. A clinical questionnaire (Appendix file) was used to collect information related to the selected items from other seven European expert clinicians (survey clinicians) The questionnaire was completed by survey clinicians related to outpatients with a diagnosis of TD (according to DSM\\V) who had been previously judged by the clinician as refractory to an anti tic monotherapy. A judgement of refractoriness implied that the clinician had already decided either to discontinue that particular anti tic monotherapy, or to change the regime by adding on another treatment. With respect to the main reason for the refractoriness judgement, refractoriness was categorised either as due to lack of efficacy at the highest tolerated dose or as due to lack of tolerability at initial or effective dosage. This studywas selectively based on the clinical information carried out as part of the routine clinical care of the patients. Sixty eight TD patients (56male, median age: 14 years; range 8 44) were enrolled consecutively across 7 European tertiary centres for TD; at each participating centre, all patients were identified by the same clinician throughout a period of 18 months. The median age at tic onset
Journal of the Neurological Sciences