As an expert in the treatment of Tourette Syndrome (TS), recently, Dr. Coffman was asked to author an article on the pharmacological treatment of Tourette Syndrome.
In collaboration with Dr. Quezada, the paper was published in CNS Drugs Journal, focusing on current approaches and new developments regarding treatment of Tourette Syndrome. The team developed a visual algorithm to help guide the treatment of TS using medication based on the level-of-evidence and side-effects. It has been designed for others to use both inside the U.S. and globally. In this podcast, Drs. Coffman and Quezada will discuss the findings of the review publication.
Tourette Syndrome: Using an Evidence-based Algorithm to Guide Treatment
Featured Speaker:
Learn more about Keith A. Coffman, MD
Julio Quezada, MD, is a fifth year child neurology resident, originally from Guatemala. He completed medical school in Guatemala and practiced for three years as a field doctor for a sugar mill, tending to the medical needs of the sugar cane field workers and their families. Dr. Quezada began his neurology/pediatrics residency in 2013 and has developed an interest in neuroethics and behavioral neurology, which includes patients with conversion disorders, Tourette Syndrome and neurobehavioral syndromes. In addition, he has completed the pediatric bioethics certificate program at Children’s Mercy.
Keith A. Coffman, MD & Julio Quezada, MD
Keith A. Coffman, MD, is Director of Tourette Syndrome Center of Excellence; Director, Movement Disorders Clinic; Associate Program Director, Child Neurology Residency Program; and Professor of Pediatrics, University of Missouri-Kansas City School of Medicine. Dr. Coffman earned his medical degree from Pennsylvania State University College of Medicine, and completed an internship and residencies in Pediatrics and Neurology at Children's Hospital of Pittsburgh. He also completed a fellowship in Child Neurology at the University of Pittsburgh School of Medicine, and has certifications in Neurodevelopmental Disabilities, Neurology with Special Qualifications in Child Neurology, and Pediatrics. In addition, Dr. Coffman has extensive knowledge in neuroanatomy.Learn more about Keith A. Coffman, MD
Julio Quezada, MD, is a fifth year child neurology resident, originally from Guatemala. He completed medical school in Guatemala and practiced for three years as a field doctor for a sugar mill, tending to the medical needs of the sugar cane field workers and their families. Dr. Quezada began his neurology/pediatrics residency in 2013 and has developed an interest in neuroethics and behavioral neurology, which includes patients with conversion disorders, Tourette Syndrome and neurobehavioral syndromes. In addition, he has completed the pediatric bioethics certificate program at Children’s Mercy.
Transcription:
Tourette Syndrome: Using an Evidence-based Algorithm to Guide Treatment
Dr. Michael Smith, MD (Host): Our topic today is Tourette’s syndrome, using an evidence-based algorithm to guide treatment. My guests are Drs. Keith Coffman and Julio Quezada. Dr. Keith Coffman is Director of the Tourette’s Syndrome Center of Excellence and the Director of the Movement Disorders Clinic at Children’s Mercy and Dr. Julio Quezada is a fifth year Child Neurology Resident. Dr. Coffman, Dr. Quezada, welcome to the show. Let’s start with you Dr. Coffman, I think a nice refresher on what Tourette’s syndrome is, how we diagnose it, classify it and how common it is would be really helpful to the listeners.
Dr. Keith Coffman, MD (Guest): Sure, Tourette’s syndrome is a neurodevelopmental disorder characterized by the presence of involuntary movements and sounds called tics. So, these movements and sounds are present in about 1% of the population worldwide and Tourette’s syndrome occurs mostly in young men. If you look overall at the rate of young men to young women; 3-4 out of every 5 people who are affected by Tourette’s syndrome is male.
Dr. Smith: Yeah, so that’s very interesting. Any thoughts on why that is?
Dr. Coffman: So, there a number of different theories, in terms of why it occurs. There is some evidence from animal models that the role of male steroid hormones or androgens may be important for generating Tourette’s syndrome symptoms and that may be why we see it much more in young men than young women.
Dr. Smith: Now Dr. Quezada, what are some of the current approaches right now or current treatments for Tourette’s syndrome and where are those treatment limitations.
Dr. Julio Quezada, MD (Guest): So, the current approach is to rely on medications that will cause the least amount of side effects, although there has been some research that has demonstrated that non-pharmacological treatments are preferred, because they have no side effects. So, doing a specific type of therapy that’s called CBIT can actually help patients with Tourette’s learn how to take control of their tics and when CBIT isn’t enough, that’s when we rely on the use of pharmacotherapy. We historically used dopamine antagonists, but as more and more research has come out, we found other types of medications that can help control tics and at the same token, not cause that many side effects.
Dr. Smith: Right, I definitely want to get into some of those newer developments. You guys published a paper together in CNS Drugs Journal recently. Why did you feel the need to publish this paper which ultimately was about guiding physicians into better treatment for Tourette’s?
Dr. Coffman: Sure. So, a big part of the current approach to Tourette’s nationwide, worldwide is that most people use the things with which they are most familiar; the medications that they were trained to use by the people that trained them. And outside of the United States, both in Europe and in Canada; there are treatment guidelines for Tourette’s that don’t exist in the United States. There aren’t any clear recommendations. So, when we were approached about writing this paper and trying to use the available scientific evidence to say this is how based on as Dr. Quezada mentioned, least side effect potential and most scientific evidence to say this is the path we recommend you follow.
Dr. Smith: Yeah and so interesting what you are saying – something that you said kind of sparked some interest in me there that often physicians are what they are trained to use in terms of medication and I think this isn’t just Tourette’s Syndrome, I think we see this kind of in many diseases, but what they are trained to do, maybe trained a few years to use, they continue to use that even though there might be some newer developments that we are not aware of. So, I think this is a great opportunity for us to maybe talk a little bit and I will give this to Dr. Quezada, what are some of those newer developments that excite you the most and that we are using now at Children’s Mercy?
Dr. Quezada: So, there are still lots of medications that need further research. One of those medications is very popular and it is cannabinoid medications, but there are also medications that work through a mechanism of inhibiting transport of monoamine neurotransmitters and they are know the VMAT transport inhibitors. These – there is actually a medication now with two big papers that are pending to be published. The medication known as valbenazine that I’m hoping will show benefit with the least amount of side effects possible.
Dr. Smith: So, Dr. Coffman could you tell us then a little bit more about the algorithm or this guide that is now being developed to help treat Tourette’s Syndrome?
Dr. Coffman: Sure, one of the reviewers for our publication had recommended that we, in addition to laying out the scientific evidence in written form, create a treatment algorithm and all of the credit in terms of how it is organized visually and the fact that it’s sort of color coded; it all goes to Dr. Quezada. He is the one that designed the visual algorithm that is in the paper, that has gotten so much attention. We actually received a spontaneous email from the senior editor about three weeks after the paper was released indicating that at that point in time; there were over 1100 downloads of the paper in less than a month and as of this morning 1400 individuals have downloaded this paper, the pdf version. So, his creation of this visual algorithm has really gained worldwide press and it far outpaced every other paper in the journal in terms of access.
Dr. Smith: Wow. Very impressive. Well Dr. Quezada, why don’t you tell us a little bit about how you came up with the idea to kind of color code this, make it a visual algorithm and tell us a little bit how it works.
Dr. Quezada: So, I’ll start by saying that when I started residency and first started seeing patients with tics; I felt pretty lost trying to figure out which medication to use, where to go and it was kind of hard figuring out exactly where to go and luckily, I had mentors like Dr. Coffman who have taught me which medications to use. But then when looking through the evidence, I saw that there are other medications out there and that there is more things out there that we weren’t utilizing as much. So, when we initially started talking about creating this algorithm; the first algorithm we did was a simple box and arrow algorithm which seemed kind of not as exciting as a color coded one. So, when we started thinking about how to make this more interesting, more appealing, more user friendly; it just seemed logical to add a color scheme that went from green that makes you think yes go with this one, to orange colors which makes you think you can use them but be careful. Sort of like a stoplight.
Dr. Smith: Very nice and so that is able to guide people and we need that. We are all so busy, we are working so hard. Having these visual type algorithms, I think is very helpful. So, Dr. Coffman obviously now the next step is to translate this into clinical practice. That’s always the big step from some good research, publication and then into clinical practice. Where do you see this visual algorithm going and is there a plan for you guys for Children’s Mercy to get this out there so that it can actually be used?
Dr. Coffman: So, absolutely. I’m privileged to currently be the co-chair of the medical advisory board for the Tourette Association of America and their biannual national conference is next week in Washington DC and I have been invited to do some talks at that conference. So without hesitation, without question I will be disseminating this to the national audience for both the Tourette Association as well as fellow colleagues who will be attending that meeting to say okay, here is a logical approach so that you as patients, you as providers don’t feel like this is being done in a guesswork type fashion and really putting it out there as here are all of the options that exist or may exist soon and to think about it in a logical way.
Dr. Smith: Well, that’s a nice timing, right, going right to a national conference, that’s wonderful. Yeah and I wish you the best of luck there. Dr. Quezada, I’m going to end with you. What would you like general practitioners, general pediatricians, community physicians, what would you like for them to know about treating Tourette’s syndrome?
Dr. Quezada: Well, I would like for them to know is that tics and Tourette’s can be treated. Patients with tics and Tourette’s not only have to live with their tics, they also have to live with social stigma of having these tics present which they cannot control. So, it is not something that they do on purpose and that starting the appropriate treatment whether it is pharmacological or non-pharmacological can go a long way in helping these patients with their quality of life and helping them avoid the stigma of having these tics. So, just not being daunted by these tics and knowing that it’s something that we can treat and it’s something that we can improve, and it can be a large impact on the patient’s quality of life.
Dr. Smith: Very nice. Dr. Coffman, Dr. Quezada, I want to thank you guys for the work that you are doing and also than you for coming on the show today. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to www.childrensmercy.org that’s www.childrensmercy.org. I’m Dr. Mike Smith. Have a great day.
Tourette Syndrome: Using an Evidence-based Algorithm to Guide Treatment
Dr. Michael Smith, MD (Host): Our topic today is Tourette’s syndrome, using an evidence-based algorithm to guide treatment. My guests are Drs. Keith Coffman and Julio Quezada. Dr. Keith Coffman is Director of the Tourette’s Syndrome Center of Excellence and the Director of the Movement Disorders Clinic at Children’s Mercy and Dr. Julio Quezada is a fifth year Child Neurology Resident. Dr. Coffman, Dr. Quezada, welcome to the show. Let’s start with you Dr. Coffman, I think a nice refresher on what Tourette’s syndrome is, how we diagnose it, classify it and how common it is would be really helpful to the listeners.
Dr. Keith Coffman, MD (Guest): Sure, Tourette’s syndrome is a neurodevelopmental disorder characterized by the presence of involuntary movements and sounds called tics. So, these movements and sounds are present in about 1% of the population worldwide and Tourette’s syndrome occurs mostly in young men. If you look overall at the rate of young men to young women; 3-4 out of every 5 people who are affected by Tourette’s syndrome is male.
Dr. Smith: Yeah, so that’s very interesting. Any thoughts on why that is?
Dr. Coffman: So, there a number of different theories, in terms of why it occurs. There is some evidence from animal models that the role of male steroid hormones or androgens may be important for generating Tourette’s syndrome symptoms and that may be why we see it much more in young men than young women.
Dr. Smith: Now Dr. Quezada, what are some of the current approaches right now or current treatments for Tourette’s syndrome and where are those treatment limitations.
Dr. Julio Quezada, MD (Guest): So, the current approach is to rely on medications that will cause the least amount of side effects, although there has been some research that has demonstrated that non-pharmacological treatments are preferred, because they have no side effects. So, doing a specific type of therapy that’s called CBIT can actually help patients with Tourette’s learn how to take control of their tics and when CBIT isn’t enough, that’s when we rely on the use of pharmacotherapy. We historically used dopamine antagonists, but as more and more research has come out, we found other types of medications that can help control tics and at the same token, not cause that many side effects.
Dr. Smith: Right, I definitely want to get into some of those newer developments. You guys published a paper together in CNS Drugs Journal recently. Why did you feel the need to publish this paper which ultimately was about guiding physicians into better treatment for Tourette’s?
Dr. Coffman: Sure. So, a big part of the current approach to Tourette’s nationwide, worldwide is that most people use the things with which they are most familiar; the medications that they were trained to use by the people that trained them. And outside of the United States, both in Europe and in Canada; there are treatment guidelines for Tourette’s that don’t exist in the United States. There aren’t any clear recommendations. So, when we were approached about writing this paper and trying to use the available scientific evidence to say this is how based on as Dr. Quezada mentioned, least side effect potential and most scientific evidence to say this is the path we recommend you follow.
Dr. Smith: Yeah and so interesting what you are saying – something that you said kind of sparked some interest in me there that often physicians are what they are trained to use in terms of medication and I think this isn’t just Tourette’s Syndrome, I think we see this kind of in many diseases, but what they are trained to do, maybe trained a few years to use, they continue to use that even though there might be some newer developments that we are not aware of. So, I think this is a great opportunity for us to maybe talk a little bit and I will give this to Dr. Quezada, what are some of those newer developments that excite you the most and that we are using now at Children’s Mercy?
Dr. Quezada: So, there are still lots of medications that need further research. One of those medications is very popular and it is cannabinoid medications, but there are also medications that work through a mechanism of inhibiting transport of monoamine neurotransmitters and they are know the VMAT transport inhibitors. These – there is actually a medication now with two big papers that are pending to be published. The medication known as valbenazine that I’m hoping will show benefit with the least amount of side effects possible.
Dr. Smith: So, Dr. Coffman could you tell us then a little bit more about the algorithm or this guide that is now being developed to help treat Tourette’s Syndrome?
Dr. Coffman: Sure, one of the reviewers for our publication had recommended that we, in addition to laying out the scientific evidence in written form, create a treatment algorithm and all of the credit in terms of how it is organized visually and the fact that it’s sort of color coded; it all goes to Dr. Quezada. He is the one that designed the visual algorithm that is in the paper, that has gotten so much attention. We actually received a spontaneous email from the senior editor about three weeks after the paper was released indicating that at that point in time; there were over 1100 downloads of the paper in less than a month and as of this morning 1400 individuals have downloaded this paper, the pdf version. So, his creation of this visual algorithm has really gained worldwide press and it far outpaced every other paper in the journal in terms of access.
Dr. Smith: Wow. Very impressive. Well Dr. Quezada, why don’t you tell us a little bit about how you came up with the idea to kind of color code this, make it a visual algorithm and tell us a little bit how it works.
Dr. Quezada: So, I’ll start by saying that when I started residency and first started seeing patients with tics; I felt pretty lost trying to figure out which medication to use, where to go and it was kind of hard figuring out exactly where to go and luckily, I had mentors like Dr. Coffman who have taught me which medications to use. But then when looking through the evidence, I saw that there are other medications out there and that there is more things out there that we weren’t utilizing as much. So, when we initially started talking about creating this algorithm; the first algorithm we did was a simple box and arrow algorithm which seemed kind of not as exciting as a color coded one. So, when we started thinking about how to make this more interesting, more appealing, more user friendly; it just seemed logical to add a color scheme that went from green that makes you think yes go with this one, to orange colors which makes you think you can use them but be careful. Sort of like a stoplight.
Dr. Smith: Very nice and so that is able to guide people and we need that. We are all so busy, we are working so hard. Having these visual type algorithms, I think is very helpful. So, Dr. Coffman obviously now the next step is to translate this into clinical practice. That’s always the big step from some good research, publication and then into clinical practice. Where do you see this visual algorithm going and is there a plan for you guys for Children’s Mercy to get this out there so that it can actually be used?
Dr. Coffman: So, absolutely. I’m privileged to currently be the co-chair of the medical advisory board for the Tourette Association of America and their biannual national conference is next week in Washington DC and I have been invited to do some talks at that conference. So without hesitation, without question I will be disseminating this to the national audience for both the Tourette Association as well as fellow colleagues who will be attending that meeting to say okay, here is a logical approach so that you as patients, you as providers don’t feel like this is being done in a guesswork type fashion and really putting it out there as here are all of the options that exist or may exist soon and to think about it in a logical way.
Dr. Smith: Well, that’s a nice timing, right, going right to a national conference, that’s wonderful. Yeah and I wish you the best of luck there. Dr. Quezada, I’m going to end with you. What would you like general practitioners, general pediatricians, community physicians, what would you like for them to know about treating Tourette’s syndrome?
Dr. Quezada: Well, I would like for them to know is that tics and Tourette’s can be treated. Patients with tics and Tourette’s not only have to live with their tics, they also have to live with social stigma of having these tics present which they cannot control. So, it is not something that they do on purpose and that starting the appropriate treatment whether it is pharmacological or non-pharmacological can go a long way in helping these patients with their quality of life and helping them avoid the stigma of having these tics. So, just not being daunted by these tics and knowing that it’s something that we can treat and it’s something that we can improve, and it can be a large impact on the patient’s quality of life.
Dr. Smith: Very nice. Dr. Coffman, Dr. Quezada, I want to thank you guys for the work that you are doing and also than you for coming on the show today. You’re listening to Transformational Pediatrics with Children’s Mercy Kansas City. For more information you can go to www.childrensmercy.org that’s www.childrensmercy.org. I’m Dr. Mike Smith. Have a great day.