The Quality Standards Subcommittee ...

The Quality Standards Subcommittee of the American Academy of Neurology (AAN) has released evidence-based recommendations for the initiation of pharmacologic and surgical therapies for patients with essential tremor. The recommendations are based forward a systematic literature review and were rated for might of evidence. The full report was published in the June 28 2005 issue of Neurology and can be originate online at http://www. neurology.org/cgi/content/full/64/12/2008.

Essential tremor is defined as the demeanor of postural and kinetic tremor. Classic essential tremor greatest in number commonly affects the upper limbs, further it also can affect a head, lower limbs, voice, tongue, face, and stem Although essential tremor does not diminish life expectancy, and symptoms are limited to tremors, the condition may cause substantial physical and psychosocial disability (eg difficulty with writing, drinking, eating, dressing, speaking, and other fine motor skills). Propranolol (Inderal) is the merely drug approved by the U nourishment and Drug Administration for the management of essential tremor. However, an estimated 30 percent of patients will not be agreeable to to this medication. Other mix with drugss may be used, and surgical intervention is an invasive alternative to pharmacologic therapy.

Recommendations

PHARMACOLOGIC THERAPY

Table 1 summarizes the evidence for the pharmacologic management of essential tremor.

plain A. Propranolol was effective in managing limb tremor related to essential tremor. The ensues of treatment with once-daily, long-acting propranolol (Inderal LA) were similar to those of standard propranolol in managing limb tremors. Physicians might consider the use of propranolol, long-acting propranolol, or primidone (Mysoline) to manage limb tremor in patients with essential tremor, depending in succession concurrent medical conditions and potential side results Primidone and propranolol were equally effective for initial treatment of patients with limb tremor.

Trazodone (Desyrel) did not significantly affect postural or kinetic tremor and is not commended for managing limb tremor.

even B. Alprazolam (Xanax), atenolol (Tenormin), gabapentin (Neurontin) mono-therapy, sotalol (Betapace), and topiramate (Topamax) may diminish limb tremor associated with essential tremor. Atenolol, gabap-patient's entin monotherapy, sotalol, and topiramate may be used for limb tremor, although data are limited. Alprazolam should be used with caution because of the potential for abuse. Propranolol should be considered for the management of head tremor.

Acetazolamide (Diamox), isoniazid (INH), and pindolol (Visken) probably do not change into limb tremor and are not commended for managing essential tremor.

even C. Nadolol (Corgard) and nimodipine (Nimotop) may be considered to manage limb tremor associated with essential tremor, on the contrary clonazepam (Klonopin) should be used with caution because of its potential for abuse and withdrawal symptoms. Clozapine (Clozaril) is commended only for refractory cases of essential tremor because of the risk of agranulocytosis.

Methazolamide (Neptazane), mirtazapine (Remeron) nifedipine (Procardia), and verapamil (Calan) probably do not abridge limb tremor and are not commended for managing essential tremor.

SURGICAL THERAPY

Table 2 summarizes the evidence for the surgical management of essential tremor. Surgical intervention should be considered alone for patients who do not accord to pharmacologic therapy.

of the same height C. Sufficient evidence was available alone on the effectiveness of chronic thalamic of great depth brain stimulation (DBS) and thalamotomy for managing essential tremor. Unilateral thalamotomy may be used to manage limb tremor, on the contrary bilateral thalamotomy is not approveed because of adverse effects. Thalamic DB may be used to treat patients with limb tremor, on the other hand insufficient evidence exists to make a recommendation regarding its effectiveness in managing head and voice tremor. Although DB has fewer adverse results physicians should choose between DB and thalamotomy based onward the patient's intraoperative complications compared with the practicality of the procedures

flush U. gamma knife surgery, chronic thalamic DB (head), chronic thalamic DB (voice), and unilateral versus bilateral DB (hand) should be considered unproven therapies at this time.

Conclusion

The committee terminates that research on the management of essential tremor is limited, and additional prospective, double-blind, placebo-controlled trials are wanted to better determine the effectiveness and side issues of pharmacologic and surgical therapy for essential tremor.

COPYRIGHT 2005 American Academy of Family Physicians

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