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.
