essential tremor enhanced primary care pathway … · 2017-04-28 · o patient has trial of...

CALGARY AND AREA

Specialist LINKLinking Physicians

EnhancedPrimaryCarePathway:EssentialTremor

1.FocusedsummaryofETrelevanttoprimarycare

EssentialTremor(ET)andParkinson’sDisease(PD)aretwoofthemostcommonmovementdisordersencounteredbyfamilydoctors;bothpresentwithtremorbutthe2disordersaretreateddifferently.ThediagnosisofETisclinicalandotherthancommonmetabolicconditions,investigationsarenotrequired.Treatmentcanproducesignificantbenefitandmaybeinitiatedwithoutaneurologyreferral.ETisthemostcommonmovementdisorder;thetremorispresentwhenholdingobjects,performingtasksandisusuallyofslightlyhigherfrequency(5-8Hz).Itisimportanttoexcludesecondaryconditionssuchashyperthyroidism,liverandrenaldysfunction/failure,anddrugscausingposturaltremor(valproate,lithium,SSRIs,SNRIs,amiodarone)asothercausesofaposturaltremor.Excessivecaffeineconsumption(morethan2or3eightozcupsofcoffeeperday,chocolate,softdrinks)canalsocausetremorthatlookslikeET.ETistypicallycharacterizedbyasignificantfamilyhistoryofthesametremorandbeneficialresponseto1-2drinksofwineorbeer(orotheralcoholicbeverage;itisimportanttoensurethatalcoholdependencyisnotpresentaspotentialself-treatment).Dependingonthefamilyhistory,thetremormaypresentatawiderangeofagesandmanypatientswithETdonotneedtreatment.However,ETisaprogressivecondition.Whenthereissufficientfunctionalimpairment(writing,usingutensils,working),itisappropriatetodiscussmedicationastreatment.

COMPARISONOFTREMORINETANDPD

EssentialTremor Parkinson’sDisease• Head/voicetremor

• Bilateralonsetoftremor,usuallyhands

• ETOHresponsive(1-2drinkswine/beer)

• Nocogwheelrigidity

• Writinglargeandtremulous

• Tremorbetterwithwalking

• Positivefamilyhistory

• Tremorpresentwithholdingobjectsorperformingtasks

• Chintremor

• Unilateralonsetoftremor/bradykinesia

• ETOHunresponsive

• Cogwheelrigidity

• Writingsmall(micrographia)

• Tremoremergeswithwalkingwithreducedarmswig

• Often,noclearfamilyhistory

• Tremorpresentatrest

October2016-2

2.Checklisttoguideyourin-clinicreviewofthispatientwithETsymptoms

o SignsofET

o NosignsofParkinsonDisease

o Ruleoutsecondaryconditions(hyperthyroidism,liver/kidneyproblems,drugscausingtremor)

o LifestylefactorsthatcontributetoEThavebeenidentifiedanddiscussedwithpatient

o Patienthastrialofpropranolol(for8-12weeks)followedbyreviewandoptimization

o Ifcontraindicationorfailedtrialofbetablockers,trialoftopiramate(for8-12weeks)followedbyreviewandoptimization

o IfnecessarytrialofthirdlinetreatmentwithPrimidone(for8-12weeks)followedbyreviewandoptimization

3.Linkstoadditionalresources

Forphysicians:

http://www.neurology.org/content/77/19/1752.full.pdf+html

http://www.mayoclinic.org/diseases-conditions/essential-tremor/home/ovc-20177826

http://www.cfp.ca/content/56/3/250.full.pdf+html

Forpatients:

UpToDate®-BeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/tremor-beyond-the-basics?source=search_result&search=essential+tremor&selectedTitle=12~31

UniversityofCalgaryDepartmentofClinicalNeurosciencesMovementclinicwebsite(especiallyresourcestab):www.dcns.ca/programs/movementdisorders

http://www.essentialtremor.org/wp-content/uploads/2013/06/patienthandbook02142013-final1.pdf

http://patient.info/health/essential-tremorhttp://tools.aan.com/professionals/practice/pdfs/ET_patients.pdf

4.ClinicalflowdiagramwithexpandeddetailThisAHSCalgaryZonepathwayhasbeendevelopedwithconsiderationoftheseguidelines.Thefollowingisbest-practiceclinicalpathwaysformanagementofETintheprimarycaremedicalhome,whichincludesaflowdiagramandexpandeddetail:

CALGARY AND AREA

Specialist LINK

Primidone Trial• Start 62.5 mg qhs, gradually increase to 125 mg bid

SUSPECTED ESSENTIAL TREMOR (ET) PATHWAYS

TREAT AS NEEDED

Non-Neurological causes:• Hyperthyroidism• Liver/Kidney• Medications

Red Flags/Exclusionary • Unilateral tremor• Signs of Parkinsonism• Rapidly progressive (weeks - months)

Confirmatory Features• Symmetrical onset• Tremor while holding objects (not at rest)• Family history of Essential Tremor present• Better with 1-2 drinks alcohol

Topiramate Trial• If no contraindications • Start 12.5 mg bid, gradually increase to 25-50 mg bid

Medication/Lifestyle Review• Alcohol - ensure no dependency• Caffeine - intake not excessive• Medication induced tremor (valproate, lithium, SS/NRIs, amiodarone)

NO

YES

NONE OF THE ABOVE OR NO IMPROVEMENT WITH D/C

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Propranolol Trial• If no contraindications • 20 prn or 240-320 mg daily or 60-80 mg LA daily

If no improvementor worsening

If no improvementor worsening

YES

IF NO IMPROVEMENT OR WORSENINGDecember, 2016

October2016-4

SUSPECTEDESSENTIALTREMORPATHWAYTrialofPropranolol• Whenwarranted,medicationsforETincludebetablockers(propranolol,preferentially),topiramateandprimidone.

• Iftherearenocontraindications(asthma,COPD,depression),propranololisconsideredfirstlinetherapy.

• Propranololmaybetakenonaprnbasisforanticipatedsituationswherethetremorwillpredictablyworsen(20mg30minutespriortoevent).

• Propranololmayalsobetakenonaregularbasis(40-80mg/dayregularor60mg-80mg/daylong-acting);allow4weeksbetweenvisitsforevaluationanddoseincreases.

• PotentialsideeffectsofPropranololincludefatigue,hypotensionandbradycardia.StartingPropranolol20mg.

Week AM PM1 ----- 1tablet(20mg)2 1tablet 1tablet3 2tablets 2tablets4 3tablets 3tabletsEVALUATE

Evaluateat60mgbid;Mayincreasefurtherasneededandastoleratedto240-320mgperday.

5 4tablets 4tablets6 5tablets 5tablets7 6tablets 6tablets

PropranololLA60or80mgmaybestartedonceperdayandincreasedtobidafterevaluation.PropranololLAisusuallytriedafterregularpropranololhasbeenproventobeeffectivebutthepatientwouldpreferonceperdaydosing.

October2016-5

TrialofTopiramate

• Topiramatemaybetriedifbeta-blockersarecontraindicatedorhavenotbeenhelpful.• ThestartingdoseofToprimatewouldbe12.5mgodincreasingthisgraduallyoveranumberofweeksto25-50mgbid.

• PotentialsideeffectsofTopiramateincluderash(drugshouldbestopped),feelingdizzyandoffbalance,weightlossandcognitiveslowing.

• Topiramateiscontraindicatedwithglaucomaornephrolithiasis.StartingTopiramate25mg

Week AM PM1 ----- ½tablet2 ½tablet ½tablet3 ½tablet 1tablet4 1tablet 1tablet

Mayincreasefurtherasneeded/toleratedto50mgbid.TrialofPrimidone• Primidonewouldbethethirddrugofchoice,butproducesthemostsideeffects.Watchparticularlyfornausea,dizzinessorproblemswithbalanceinelderlypatients.

• ThestartingdoseforPrimidoneis62.5mgqhsandincreasethemedicationweeklyuntil125mgbid;titrationmaybeslowerifsideeffectsdevelop.

• ThedoseofPrimidonemaybegraduallyincreasedto250mgbid,butgenerally,sideeffectslimitincreasingthemedicationtothisdose.

• Forpatientsonwarfarin,theINRshouldbewatchedforpotentialchangeswhileonPrimidone.StartingPrimidone125mg

Week AM PM1 ----- ½tablet2 ½tablet ½tablet3 ½tablet 1tablet4 1tablet 1tablet

Evaluateat125mgbid;increaseastoleratedto250mgbid.