Guideline for the treatment of essential tremor

Essential Tremor (ET) is a chronic condition characterized by involuntary, rhythmic tremor of a body part, usually the hands and arms. In most patients, ET is considered a slowly progressive disorder and, in some patients, may eventually involve the head, voice, tongue (with associated dysarthria), legs, and trunk. However, in many people, the disease may be relatively non- progressive and the tremor may be mild throughout life. In some patients with ET, other neurologic symptoms may also be present. These seems to be more frequent in older patients or those with long-standing disease ( >5 years' duration). The diagnosis of ET remains a visual one however it is important to eliminate any other conditions which may also produce tremor as a symptom e.g. tumours or damage to the brain. Blood samples should be taken to rule out thyroid or copper metabolism problems, both of which can cause tremor. DATScan a diagnostic test can distinguish between ET and tremors of Parkinson's disease. If, having followed the pathway below, symptoms cannot be managed consider referral to neurology for ongoing management.

Self help techniques; The following things may help to reduce/manage patients symptoms: • Avoid caffeine (found in tea and coffee) • Relaxation techniques such as yoga • Avoid stress • Sufficient sleep • use of heavier cutlery when eating • use of a heavier cup when drinking and drinking through a straw • type instead of writing

Patients may find more information from www.tremor.org.uk

Treatment should be trialled for at least 8 weeks at maximally tolerated dose before moving onto the next choice. If symptoms cannot be controlled by following through this pathway refer for on-going management.

Beta blocker intolerant/Contra- indicated Preliminary treatment

Propranolol Primidone Start low dose and titrate to Start low dose 50mg at night and maximum 40mg bd titrate to maximum 250mg tds (over approx. 6 weeks-use 50mg tablets for titration only)

If unsuccessful change to; Propranolol and Primidone Gabapentin* combination Start low dose (300mg daily) and See doses above titrate to 600mg bd (Reduce dose in renal impairment see datasheet)

If unsuccessful change to;

Propranolol and Gabapentin* Topiramate*

combination 50mg mane and 100mg nocte

See doses above (Use with caution if eGFR< 60)

If unsuccessful change to;

Topiramate* Clonazepam* 50mg mane and 100mg nocte 0.25mg nocte increasing to maximum 0.5mg bd

If unsuccessful change to;

Clonazepam* 0.25mg nocte increasing to maximum 0.5mg bd

* Product currently does not hold a UK product licence for use in essential tremor

Approved by: Area prescribing committee Chairman : Dr Alan Jackson Written by: Clare Drain under guidance of Dr Sigga Sveinbjornsdottir Date: July 2013 Review date: July 2015