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AI-Generated response:

What is the first line treatment for essential tremor?

Answer generated on June 4, 2024

The AI-generated responses are for illustration purposes only and should not be used for medical purposes.

The first-line treatments for essential tremor are propranolol and primidone.

Propranolol can cause side effects such as dizziness, fatigue, and hypotension, while primidone may cause nausea, dizziness, ataxia, confusion, and sedation.[1-4]

  • Propranolol is typically started at 40 mg orally twice daily, with the dose possibly increased to 120-320 mg/day in divided doses.[3]

  • Primidone should be started at 25 to 62.5 mg orally per day, usually at night to increase tolerability, with a gradual increase to a target dose range of 250 to 750 mg/day in divided doses.[2]

  • Both medications are considered synergistic when used together for patients with disabling essential tremor that cannot be managed with monotherapy.[4]

  • Propranolol and primidone are both established as effective treatments for essential tremor by clinical practice guidelines.[2-3]

  • Alternative medications include topiramate and gabapentin, but they are generally considered after propranolol and primidone.[1]

Additional info

When considering treatment options for essential tremor, it's important to assess the severity and impact of the tremor on the patient's daily activities. The choice between propranolol and primidone may depend on the patient's specific health profile and potential side effects. For instance, propranolol should be used cautiously in patients with asthma or certain cardiovascular conditions due to its beta-blocking effects. Primidone, being a barbiturate, requires careful monitoring due to its potential for sedation and cognitive effects, especially in the elderly. In cases where tremor is resistant to these medications, other therapeutic options such as botulinum toxin injections or surgical interventions like deep brain stimulation may be considered, although these are generally reserved for more severe cases.[1][4]

References

Reference 1

1.

Okun, Michael S., Ostrem, Jill L. (2024). In Goldman-Cecil Medicine (pp. 2489). DOI: 10.1016/B978-0-323-93038-3.00379-8

Treatment of essential tremor does not influence the course of the illness and therefore is justified only when the tremor interferes with function. At least 50% of patients note improvement or complete amelioration of tremor following the ingestion of a small amount of ethanol.First-line drug treatment includes trials of a noncardioselective β-adrenergic blocker (e.g., propranolol, ≤320mg/day), primidone (starting in a low dose of 25 to 62.5mg at night and increasing to 250 and sometimes 500 to 750mg/day if tolerated), or topiramate (≤400mg/day).Other drugs that have been shown probably to be effective in double-blind crossover trials include gabapentin (1200 to 1800 mg/day), atenolol (50 to 150mg/day), alprazolam (0.125 to 3mg/day), and sotalol (75 to 200mg/day). However, sotalol is associated with ventricular arrhythmias and dose-related QT interval prolongation, so it is not routinely considered as treatment of essential tremor. The medications that have been shown to be of possible benefit include nadolol (120 to 240mg/day), nimodipine (120mg/day), and clonazepam (0.5 to 6 mg/day), but many patients remain resistant to all drugs. Botulinum toxin may be effective for up to 18 weeks, but it often results in dose-dependent weakness and pain at the injection site.If disability is substantial, thalamic deep brain stimulationor focused ultrasound thalamotomycan be of major benefit, with significant reductions following unilateral or bilateral treatment.However, a few patients suffer permanent neurologic sequelae such as speech and gait dysfunction even with unilateral procedures, and even more suffer such problems after bilateral procedures.

Reference 2

2.

Elsevier ClinicalKey Drug Monograph

Content last updated: May 4, 2024.

Indications And Dosage Oral dosage Adults: Clinical practice guidelines of the American Academy of Neurology consider primidone effective for the treatment of essential tremor (Level A, established). Give 25 to 62.5 mg/day PO initially, usually at night to increase tolerability. Increase as tolerated and needed by titrating the daily dose by 25 mg every 3 days. Titration to optimal dosing may take several weeks to limit intolerance. In clinical trials, the effective target dose range was 250 to 750 mg/day PO, given in divided doses. Mean effective dose average: 481.7 mg/day PO. Maximum suggested dose: 750 mg/day PO (i.e., 250 mg PO 3 times daily). Early side effects (e.g., nausea, dizziness, ataxia, confusion, sedation) attenuate after a few months of treatment; mild sedation may remain at higher daily doses.

Reference 3

3.

Elsevier ClinicalKey Drug Monograph

Content last updated: April 2, 2024.

Indications And Dosage Oral dosage (immediate-release tablets or oral solution) Adults: 40 mg PO twice daily. Increase dose as needed to 120 to 320 mg/day PO given in 2 to 3 divided doses. In geriatric patients, begin with conservative initial doses and titrate carefully; geriatric patients have unpredictable responses to beta-blockers. Clinical practice guidelines consider inderal la effective for the treatment of essential tremor.

Reference 4

4.

Reich SG. The Medical Clinics of North America. 2019;103(2):351-356. doi:10.1016/j.mcna.2018.10.016.

Publish date: March 5, 2019.

Essential tremor is one of the most common movement disorders. It is characterized by a bilateral action tremor of the upper limbs. It may be accompanied by tremor of the head, voice, or lower limbs. Essential tremor is often present for years or decades before presentation and it progresses insidiously. It is often familial and transiently responsive to alcohol. For patients requiring treatment, the two first-line medications are propranolol and primidone, which are synergistic. Patients with disabling essential tremor that cannot be managed medically are candidates for either deep brain stimulation or focused ultrasound.

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