Cardiometabolic Risks Increased With Tourette, Tic Disorders

Nancy A. Melville

January 16, 2019

People with Tourette syndrome and chronic tic disorder (CTD) are nearly twice as likely to develop a cardiometabolic disorder such as obesity or diabetes compared with those without the disorders, with the increased risk observed beginning in childhood, new research suggests.

"Our findings underscore the importance of carefully monitoring cardiometabolic health in patients with Tourette syndrome and CTD from an early age," senior author Lorena Fernández de la Cruz, MD, assistant professor, Department of Clinical Neuroscience at Karolinska Institute, Stockholm, Sweden, told theheart.org | Medscape Cardiology.

"These results are entirely novel, and we hope they will be helpful to clinicians working with this patient group."

Tic disorders are known to be linked to a variety of adverse health concerns, even including premature death. However, research on the underlying factors potentially elevating those risks is lacking, the researchers say.

To take a closer look, Fernández de la Cruz and colleagues identified 7804 individuals who were among more than 14 million in a longitudinal Swedish population cohort to develop Tourette syndrome or CTD between 1973 and 2013.

The findings, published online January 14 in JAMA Neurology, showed that those with either Tourette syndrome or CTD had a significantly higher risk of developing any metabolic or cardiovascular disorders, with a hazard ratio, adjusted by sex and age, of 1.99 (95% confidence interval [CI], 1.90 - 2.09).

In a subgroup of patients with Tourette syndrome or CTD who could be compared to sibling controls, the risk was somewhat attenuated, but still exceeded the general population (adjusted hazard ratio [aHR] 1.37, 95% CI, 1.24 - 1.50).

"The risk was still elevated for the cohort of Tourette syndrome/CTD individuals when compared to their siblings, indicating that at least part of the risk for cardiometabolic disorders might be due to the tics themselves," Fernández de la Cruz noted.

In terms of specific disorders, after adjustment for various factors, individuals with Tourette syndrome or CTD had higher risks of obesity (aHR, 2.76; 95% CI, 2.47 - 3.09), type 2 diabetes (aHR, 1.67; 95% CI, 1.42 - 1.96), and circulatory system diseases (aHR, 1.76; 95% CI, 1.67 - 1.86).

Men with Tourette syndrome or CTD had a significantly higher risk of having any cardiometabolic disorder compared to women (aHR, 2.13; 95% CI, 2.01 - 2.26 vs aHR, 1.79; 95% CI, 1.64 - 1.96), and their risk of obesity was also higher when each was compared to the general population (aHR, 3.24; 95% CI, 2.83 - 3.70 vs aHR, 1.97; 95% CI, 1.59 - 2.44).

The increased risk of cardiometabolic disorders was observed as early as age 8, and overall, the risk of developing at least one cardiometabolic disorder by the end of the follow-up, at an average age of 41 years, was 52.5% in people with Tourette syndrome/CTD, compared with 29.5% in the general population, which is consistent with the literature on the general population.

ADHD May Compound the Risk

The exclusion of comorbidities did not change the results, with one notable exception — when excluding those with attention deficit hyperactivity disorder (ADHD), the risk of cardiometabolic disorders, though still higher than the general population, was significantly reduced (aHR, 1.52; 95% CI, 1.42 - 1.62).

The finding is important in light of the fact that ADHD was the most prevalent comorbid condition in the Tourette syndrome/CTD cohort, with nearly half of the individuals also having a diagnosis of ADHD, Fernández de la Cruz noted.

"Patients with both tic disorders and ADHD should be considered a particularly important group to monitor when it comes to these complications," she said.

In an exploratory analysis, antipsychotic medication use for more than 1 year was associated with a significantly decreased risk of cardiometabolic disorders (aHR, 0.27; 95% CI, 0.17 - 0.43).

But while similar apparent protective effects of antipsychotic medication have been observed in other neuropsychiatric disorders, such as obsessive-compulsive disorder (OCD) and schizophrenia, Fernández de la Cruz warned that the findings involving antipsychotics have some important caveats.

"Since this is an observational study, the finding indicating that the use of antipsychotic medication for a long period of time is seemingly protective needs to be interpreted with caution," she said.

"In our opinion, this finding is likely to reflect a greater medical vigilance since Tourette syndrome/CTD patients on medication are more likely to have frequent follow-ups and receive closer monitoring," she added. "However, as previous treatment studies have shown, antipsychotics are not free from cardiometabolic adverse effects and they should continue being used with caution."

The stresses and lifestyle factors that are associated with increased cardiometabolic risks in other psychiatric disorders could also explain those seen in Tourette syndrome and CTD, the authors say.

"Individuals with Tourette syndrome or CTD experience a substantial number of stressors in their daily lives, have poorer educational outcomes, and, like individuals with other neuropsychiatric disorders, might have unhealthier lifestyles (eg, lack of physical activity and poor diet), which have also been shown to be associated with the development of metabolic and cardiovascular diseases," they write.

Important Implications

Commenting for theheart.org | Medscape Cardiology, Carol A. Mathews, MD, Department of Psychiatry, University of Florida in Gainesville, said the study, considered the largest of its kind, has important implications.

"It is a clinically important study in that it suggests that psychiatrists and neurologists and other healthcare providers should routinely screen for cardiovascular and metabolic disorders among individuals with Tourette syndrome, including children," said Mathews, who is the co-chair of the scientific advisory board of the Tourette Association of America.

"The risk for these disorders is twice as high in people with Tourette syndrome/CTD than in healthy control individuals. It is also important in that the increased risk for these disorders is apparent in early childhood, although it is not until age 20 that the incidence is over 10%."  

Mathews agreed that a host of factors could explain the increased risks observed in the study.

"I think that it is likely to be multifactorial — a combination of factors, including closer monitoring of these patients by providers, possibly higher genetic risk, lifestyle factors, and possibly even medications other than those studied," she speculated.

In addition to routinely screening patients, Mathews encouraged professionals working with Tourette syndrome/CTD patients to help them manage their weight by exercising, eating healthily, and minimizing their screen time, as well as limiting medications that might increase risk for cardiovascular or metabolic problems.

The study received support through a research grant from Tourettes Action and the Swedish Research Council for Health, Working Life and Welfare (FORTE). Mathews is the co-chair of the scientific advisory board of the Tourette Association of America.

JAMA Neurology. Published January 14, 2019. Abstract

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