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Essential tremor, also known as essential tremor, is a common movement disorder
.
The "Guidelines for Primary Diagnosis and Treatment of Essential Tremor (2021)" systematically elaborated on the definition, classification, diagnosis and differential diagnosis, referral, treatment, disease management and prognosis of essential tremor
.
Regarding the drug treatment of essential tremor, the guidelines mainly involve the following
.
First-line drug therapy (1) Propranolol: a non-selective β1 and β2 adrenergic receptor blocker.
It is a classic first-line drug treatment.
It can improve the amplitude of limb tremor in about 50% of patients, but it is resistant to axial tremor ( Such as head, speech, etc.
) has no obvious effect
.
It is generally recommended to start with a small dose (10 mg/time, 2 times/d), and gradually increase the dose (5 mg/time) to 30~60 mg/d to improve symptoms, generally not more than 360 mg/d, and the maintenance dose is 60~240 mg/d
.
Standard tablets 3 times/d, controlled-release tablets 1 time/d, taken in the morning, can significantly reduce the amplitude of tremor within 2 hours
.
Common adverse reactions include heart rate reduction and blood pressure drop, but heart rate not less than 60 beats/min can be basically tolerated.
During medication, heart rate and blood pressure changes should be closely observed.
If heart rate <60 beats/min, consider reducing the amount, <55 Times/min, the drug was discontinued
.
It is relatively contraindicated for patients with heart block, asthma, diabetes and other diseases, but it can be used to treat essential tremor of stable heart dysfunction with left ventricular systolic dysfunction
.
(2) Arotinolol: It has α and β receptor blocking effect (the action ratio is roughly 1:8), which can reduce the amplitude of postural tremor and action tremor, and the effect is similar to propranolol
.
Compared with propranolol, arolol has 4 to 5 times its β-receptor blocking activity, and it is not easy to pass through the blood-brain barrier, and it will not produce central nervous system adverse reactions like propranolol
.
Therefore, patients who cannot tolerate propranolol can be considered for treatment with this drug
.
Generally start from 10 mg/time, 1 time/d.
If the effect is not sufficient, increase the dose to 10 mg/time, 2 times/d, and the maximum dose should not exceed 30 mg/d
.
Common adverse reactions include bradycardia, dizziness, and hypotension
.
During medication, the heart rate and blood pressure changes should be closely observed.
If the heart rate is less than 60 beats/min or there is obvious hypotension, the dose should be reduced or the medication should be stopped
.
(3) Primidone: It is an anticonvulsant.
The main metabolites in the body are phenobarbital and phenethyl diacylamine (PEMA).
Both prodrugs and metabolites can improve symptoms.
Effectively reduce the amplitude of hand tremor by 40%~50%, so the improvement of primidone on tremor is better than that of phenobarbital and PEMA alone
.
Advocate multiple administrations in small amounts, the first dose should not exceed 25 mg/d, generally starting from 25 mg every night, gradually increasing the dose 25 mg/time, the effective dose is 50~500 mg/d, orally 2~3 times a day, generally 250 mg/d has good efficacy and good tolerability
.
Patients who cannot tolerate primidone can use phenobarbital
.
In the early stage of medication, the incidence of acute adverse reactions is relatively high, including dizziness, nausea, vomiting, unstable walking, drowsiness, acute toxicity, etc.
, but most of them are temporary and do not need to be discontinued
.
Second-line drug treatment (1) Gabapentin: It is a gamma-aminobutyric acid analog, which belongs to a new type of anti-epileptic drugs and anti-neuralgia drugs
.
It is mainly used to select propranolol and primidone who have contraindications, or who cannot tolerate these two drugs
.
The starting dose is 300 mg/d, and the effective dose is 1 200-3 600 mg/d, taken in 3 divided doses
.
Common adverse reactions include drowsiness, dizziness, fatigue, and unsteady walking.
They are generally mild and disappear after 2 weeks of medication
.
(2) Topiramate: It is also a new type of anti-epileptic drug, which can improve all kinds of tremors to a certain extent
.
The initial dose is 25 mg/d, and the dose is slowly increased at an increasing rate of 25 mg/week.
The conventional treatment dose is 200-400 mg/d, orally in 2 doses
.
It is recommended to take it twice a day or before going to bed to reduce its adverse reactions
.
Topiramate may be the most effective among second-line drugs, and its effects are equivalent to those of first-line drugs, but the central nervous system has the most significant adverse reactions.
Nystagmus, drowsiness, and diplopia are dose-related.
Other adverse reactions include loss of appetite, weight loss, nausea, paresthesia, upper respiratory tract infection, kidney stones, cognitive dysfunction
.
(3) Alprazolam: It is a short-acting benzodiazepine preparation that can reduce the amplitude of tremor by 25% to 34%.
It can be used for the elderly who cannot tolerate propranolol, arolol and primidone For patients, it can relieve the aggravated tremor under anxiety, stress and other situations
.
The initial dose is 0.
6 mg/d, the initial dose for the elderly is 0.
125~0.
250 mg/d, and the effective dose is 0.
6~2.
4 mg/d, administered in 3 divided doses, and the average effective dose is 0.
75 mg/d
.
Adverse reactions include excessive sedation, fatigue, unresponsiveness, etc.
Long-term use may cause drug dependence, so use with caution
.
(4) Clonazepam: It is a long-acting benzodiazepine preparation that can effectively reduce the amplitude of action tremor
.
The initial dose is 0.
5 mg/d, and the average effective dose is 1.
5 to 2.
0 mg/d
.
Adverse reactions are dizziness, unsteady walking, excessive sedation, etc.
Use this medicine with caution, because there is a risk of abuse and withdrawal syndrome may occur
.
(5) Atenolol: It is a selective β1 receptor blocker, which is less effective than non-selective adrenergic receptor blockers.
It is suitable for asthma that cannot use β2 and non-selective adrenergic receptor blockers.
Patient
.
50~150 mg/d can relieve symptoms
.
Adverse reactions include dizziness, nausea, cough, dry mouth, and drowsiness
.
(6) Sotalol: It is a non-selective β-receptor blocker, usually used to control arrhythmia, and has a certain anti-tremor effect
.
A clinical randomized controlled study showed that sotalol 80 mg/time, 2 times/d can effectively improve the tremor symptoms of patients with essential tremor
.
Adverse reactions include nausea, vomiting, diarrhea, tiredness, lethargy, skin rash, etc.
Overdose can cause bradycardia, conduction block, and hypotension
.
Third-line drug therapy (1) The non-selective beta-blocker nadolol 120~240 mg/d, or the calcium antagonist nimodipine 120 mg/d, may be effective in improving limb tremor
.
(2) Multi-point intramuscular injection of type A botulinum toxin has more advantages in head and voice tremor, and can also be used for the treatment of limb tremor, but there are dose-related adverse reactions
.
A single dose of 40~400 IU of botulinum toxin type A can improve head tremor; multi-point injection of 50~100 IU of the flexor carpi ulna and carpi radialis can reduce the amplitude of tremor of the upper limbs.
The average treatment time is 12 weeks.
(Generally 4~16 weeks); 0.
6~15.
0 IU soft palate injection can improve voice tremor, but adverse reactions such as hoarseness and dysphagia may occur; botulinum toxin type A is a symptomatic treatment measure for refractory tremor, usually 1 The effect of one injection lasts for 3 to 6 months, and repeated injections are required to maintain the effect
.
The above content is extracted from: Chinese Medical Association, Chinese Medical Association Journal, Chinese Medical Association General Practice Branch, etc.
Primary tremor diagnosis and treatment guidelines (2021)[J] .
Chinese Journal of General Practitioners, 2021,20(10 ): 1030-1036.
.
The "Guidelines for Primary Diagnosis and Treatment of Essential Tremor (2021)" systematically elaborated on the definition, classification, diagnosis and differential diagnosis, referral, treatment, disease management and prognosis of essential tremor
.
Regarding the drug treatment of essential tremor, the guidelines mainly involve the following
.
First-line drug therapy (1) Propranolol: a non-selective β1 and β2 adrenergic receptor blocker.
It is a classic first-line drug treatment.
It can improve the amplitude of limb tremor in about 50% of patients, but it is resistant to axial tremor ( Such as head, speech, etc.
) has no obvious effect
.
It is generally recommended to start with a small dose (10 mg/time, 2 times/d), and gradually increase the dose (5 mg/time) to 30~60 mg/d to improve symptoms, generally not more than 360 mg/d, and the maintenance dose is 60~240 mg/d
.
Standard tablets 3 times/d, controlled-release tablets 1 time/d, taken in the morning, can significantly reduce the amplitude of tremor within 2 hours
.
Common adverse reactions include heart rate reduction and blood pressure drop, but heart rate not less than 60 beats/min can be basically tolerated.
During medication, heart rate and blood pressure changes should be closely observed.
If heart rate <60 beats/min, consider reducing the amount, <55 Times/min, the drug was discontinued
.
It is relatively contraindicated for patients with heart block, asthma, diabetes and other diseases, but it can be used to treat essential tremor of stable heart dysfunction with left ventricular systolic dysfunction
.
(2) Arotinolol: It has α and β receptor blocking effect (the action ratio is roughly 1:8), which can reduce the amplitude of postural tremor and action tremor, and the effect is similar to propranolol
.
Compared with propranolol, arolol has 4 to 5 times its β-receptor blocking activity, and it is not easy to pass through the blood-brain barrier, and it will not produce central nervous system adverse reactions like propranolol
.
Therefore, patients who cannot tolerate propranolol can be considered for treatment with this drug
.
Generally start from 10 mg/time, 1 time/d.
If the effect is not sufficient, increase the dose to 10 mg/time, 2 times/d, and the maximum dose should not exceed 30 mg/d
.
Common adverse reactions include bradycardia, dizziness, and hypotension
.
During medication, the heart rate and blood pressure changes should be closely observed.
If the heart rate is less than 60 beats/min or there is obvious hypotension, the dose should be reduced or the medication should be stopped
.
(3) Primidone: It is an anticonvulsant.
The main metabolites in the body are phenobarbital and phenethyl diacylamine (PEMA).
Both prodrugs and metabolites can improve symptoms.
Effectively reduce the amplitude of hand tremor by 40%~50%, so the improvement of primidone on tremor is better than that of phenobarbital and PEMA alone
.
Advocate multiple administrations in small amounts, the first dose should not exceed 25 mg/d, generally starting from 25 mg every night, gradually increasing the dose 25 mg/time, the effective dose is 50~500 mg/d, orally 2~3 times a day, generally 250 mg/d has good efficacy and good tolerability
.
Patients who cannot tolerate primidone can use phenobarbital
.
In the early stage of medication, the incidence of acute adverse reactions is relatively high, including dizziness, nausea, vomiting, unstable walking, drowsiness, acute toxicity, etc.
, but most of them are temporary and do not need to be discontinued
.
Second-line drug treatment (1) Gabapentin: It is a gamma-aminobutyric acid analog, which belongs to a new type of anti-epileptic drugs and anti-neuralgia drugs
.
It is mainly used to select propranolol and primidone who have contraindications, or who cannot tolerate these two drugs
.
The starting dose is 300 mg/d, and the effective dose is 1 200-3 600 mg/d, taken in 3 divided doses
.
Common adverse reactions include drowsiness, dizziness, fatigue, and unsteady walking.
They are generally mild and disappear after 2 weeks of medication
.
(2) Topiramate: It is also a new type of anti-epileptic drug, which can improve all kinds of tremors to a certain extent
.
The initial dose is 25 mg/d, and the dose is slowly increased at an increasing rate of 25 mg/week.
The conventional treatment dose is 200-400 mg/d, orally in 2 doses
.
It is recommended to take it twice a day or before going to bed to reduce its adverse reactions
.
Topiramate may be the most effective among second-line drugs, and its effects are equivalent to those of first-line drugs, but the central nervous system has the most significant adverse reactions.
Nystagmus, drowsiness, and diplopia are dose-related.
Other adverse reactions include loss of appetite, weight loss, nausea, paresthesia, upper respiratory tract infection, kidney stones, cognitive dysfunction
.
(3) Alprazolam: It is a short-acting benzodiazepine preparation that can reduce the amplitude of tremor by 25% to 34%.
It can be used for the elderly who cannot tolerate propranolol, arolol and primidone For patients, it can relieve the aggravated tremor under anxiety, stress and other situations
.
The initial dose is 0.
6 mg/d, the initial dose for the elderly is 0.
125~0.
250 mg/d, and the effective dose is 0.
6~2.
4 mg/d, administered in 3 divided doses, and the average effective dose is 0.
75 mg/d
.
Adverse reactions include excessive sedation, fatigue, unresponsiveness, etc.
Long-term use may cause drug dependence, so use with caution
.
(4) Clonazepam: It is a long-acting benzodiazepine preparation that can effectively reduce the amplitude of action tremor
.
The initial dose is 0.
5 mg/d, and the average effective dose is 1.
5 to 2.
0 mg/d
.
Adverse reactions are dizziness, unsteady walking, excessive sedation, etc.
Use this medicine with caution, because there is a risk of abuse and withdrawal syndrome may occur
.
(5) Atenolol: It is a selective β1 receptor blocker, which is less effective than non-selective adrenergic receptor blockers.
It is suitable for asthma that cannot use β2 and non-selective adrenergic receptor blockers.
Patient
.
50~150 mg/d can relieve symptoms
.
Adverse reactions include dizziness, nausea, cough, dry mouth, and drowsiness
.
(6) Sotalol: It is a non-selective β-receptor blocker, usually used to control arrhythmia, and has a certain anti-tremor effect
.
A clinical randomized controlled study showed that sotalol 80 mg/time, 2 times/d can effectively improve the tremor symptoms of patients with essential tremor
.
Adverse reactions include nausea, vomiting, diarrhea, tiredness, lethargy, skin rash, etc.
Overdose can cause bradycardia, conduction block, and hypotension
.
Third-line drug therapy (1) The non-selective beta-blocker nadolol 120~240 mg/d, or the calcium antagonist nimodipine 120 mg/d, may be effective in improving limb tremor
.
(2) Multi-point intramuscular injection of type A botulinum toxin has more advantages in head and voice tremor, and can also be used for the treatment of limb tremor, but there are dose-related adverse reactions
.
A single dose of 40~400 IU of botulinum toxin type A can improve head tremor; multi-point injection of 50~100 IU of the flexor carpi ulna and carpi radialis can reduce the amplitude of tremor of the upper limbs.
The average treatment time is 12 weeks.
(Generally 4~16 weeks); 0.
6~15.
0 IU soft palate injection can improve voice tremor, but adverse reactions such as hoarseness and dysphagia may occur; botulinum toxin type A is a symptomatic treatment measure for refractory tremor, usually 1 The effect of one injection lasts for 3 to 6 months, and repeated injections are required to maintain the effect
.
The above content is extracted from: Chinese Medical Association, Chinese Medical Association Journal, Chinese Medical Association General Practice Branch, etc.
Primary tremor diagnosis and treatment guidelines (2021)[J] .
Chinese Journal of General Practitioners, 2021,20(10 ): 1030-1036.
