Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology.
Practice parameter: therapies for essential tremor: report of the Quality Standards Subcommittee of the American Academy of Neurology.
1 June 2005
American Academy of Neurology - Medical Specialty Society
Summary,
GUIDELINE OBJECTIVE(S)
* To answer the following questions with regard to the pharmacologic treatment for essential tremor (ET):
o What are the safety, tolerability, and efficacy of pharmacologic agents in treating ET?
o Which drug should be used for initial treatment of ET?
o Is combined treatment with primidone and propranolol better than monotherapy?
o Is there evidence for sustained benefit of pharmacologic treatment of ET?
o Do patients with ET benefit from chemodenervation with botulinum toxin type A or B?
* To answer the following questions with regard to the surgical treatment for ET:
o What is the efficacy of thalamotomy in treating contralateral limb tremor in patients with ET?
o What is the efficacy of deep brain stimulation (DBS) of the thalamus in treating tremor in patients with refractory ET?
o Should thalamotomy or deep brain stimulation of the thalamus be the procedure of choice in patients with medically refractory ET?
o What are the indications for bilateral versus unilateral surgical procedures in ET?
TARGET POPULATION
Patients with essential tremor (ET)
INTERVENTIONS AND PRACTICES CONSIDERED
Pharmacologic Treatment
1. Propranolol (Inderal)
2. Propranolol LA (Inderal LA)
3. Primidone (Mysoline)
4. Alprazolam (Xanax)
5. Atenolol (Tenormin)
6. Gabapentin (Neurontin) as monotherapy
7. Sotalol (Sotacor)
8. Topiramate (Topamax)
9. Clonazepam (Klonopin)
10. Clozapine (Clozaril)
11. Nadolol (Corgard)
12. Nimodipine (Nimotop)
13. Botulinum toxin A
14. Considered, but not recommended:
* Trazodone (Desyrel)
* Acetazolamide (Diamox)
* Isoniazid (Laniazid, Nydrazid)
* Pindolol (Visken)
* Methazolamide (Neptazane)
* Mirtazapine (Remeron)
* Nifedipine (Adalat, Procardia)
* Verapamil (Calan)
* Amantadine (Symmetrel)
* Clonidine (Catapres)
* Gabapentin as adjunct therapy
* Glutethimide (Doriden)
* L-tryptophan/pyridoxine
* Metoprolol (Lopressor, Toprol)
* Nicardipine (Cardene)
* Olanzapine (Zyprexa)
* Phenobarbital (Luminal)
* Quetiapine (Seroquel)
* Theophylline (Theo-dur)
Nonpharmacologic (Surgical) Therapy 1. Chronic thalamic deep brain stimulation (DBS) (recommended for limb tremor, but not recommended for head or voice tremor) 2. Thalamotomy * Unilateral * Bilateral (considered, but not recommended) 3. Gamma knife thalamotomy (considered, but not recommended) MAJOR OUTCOMES CONSIDERED * Tremor suppression (magnitude of effect, duration of effect) * Adverse events severity
American Academy of Neurology - Medical Specialty Society
Summary,
GUIDELINE OBJECTIVE(S)* To answer the following questions with regard to the pharmacologic treatment for essential tremor (ET):
o What are the safety, tolerability, and efficacy of pharmacologic agents in treating ET?
o Which drug should be used for initial treatment of ET?
o Is combined treatment with primidone and propranolol better than monotherapy?
o Is there evidence for sustained benefit of pharmacologic treatment of ET?
o Do patients with ET benefit from chemodenervation with botulinum toxin type A or B?
* To answer the following questions with regard to the surgical treatment for ET:
o What is the efficacy of thalamotomy in treating contralateral limb tremor in patients with ET?
o What is the efficacy of deep brain stimulation (DBS) of the thalamus in treating tremor in patients with refractory ET?
o Should thalamotomy or deep brain stimulation of the thalamus be the procedure of choice in patients with medically refractory ET?
o What are the indications for bilateral versus unilateral surgical procedures in ET?
TARGET POPULATION
Patients with essential tremor (ET)
INTERVENTIONS AND PRACTICES CONSIDERED
Pharmacologic Treatment
1. Propranolol (Inderal)
2. Propranolol LA (Inderal LA)
3. Primidone (Mysoline)
4. Alprazolam (Xanax)
5. Atenolol (Tenormin)
6. Gabapentin (Neurontin) as monotherapy
7. Sotalol (Sotacor)
8. Topiramate (Topamax)
9. Clonazepam (Klonopin)
10. Clozapine (Clozaril)
11. Nadolol (Corgard)
12. Nimodipine (Nimotop)
13. Botulinum toxin A
14. Considered, but not recommended:
* Trazodone (Desyrel)
* Acetazolamide (Diamox)
* Isoniazid (Laniazid, Nydrazid)
* Pindolol (Visken)
* Methazolamide (Neptazane)
* Mirtazapine (Remeron)
* Nifedipine (Adalat, Procardia)
* Verapamil (Calan)
* Amantadine (Symmetrel)
* Clonidine (Catapres)
* Gabapentin as adjunct therapy
* Glutethimide (Doriden)
* L-tryptophan/pyridoxine
* Metoprolol (Lopressor, Toprol)
* Nicardipine (Cardene)
* Olanzapine (Zyprexa)
* Phenobarbital (Luminal)
* Quetiapine (Seroquel)
* Theophylline (Theo-dur)
Nonpharmacologic (Surgical) Therapy 1. Chronic thalamic deep brain stimulation (DBS) (recommended for limb tremor, but not recommended for head or voice tremor) 2. Thalamotomy * Unilateral * Bilateral (considered, but not recommended) 3. Gamma knife thalamotomy (considered, but not recommended) MAJOR OUTCOMES CONSIDERED * Tremor suppression (magnitude of effect, duration of effect) * Adverse events severity
