From the Guidelines
The most appropriate initial pharmacotherapy for this patient is not listed among the options, but based on the provided evidence, a beta-blocker such as propranolol would be the most suitable choice, however, since it's not available, the next best option would be Primidone, as it is a well-established alternative for essential tremor treatment. This patient presents with classic essential tremor, characterized by bilateral hand tremor that worsens with specific activities like writing and holding objects, is exacerbated by caffeine, improved with alcohol, and has a positive family history. According to 1, beta-blockers, such as propranolol, have been used to treat essential tremor for more than 40 years, and other beta-blockers like metoprolol may also be effective. However, since propranolol is not among the options, and considering the patient's coronary artery disease and hyperlipidemia, primidone would be a reasonable alternative.
- Carbidopa-levodopa is used for Parkinson's disease, not essential tremor.
- Lorazepam may temporarily help tremor but isn't appropriate for long-term management due to dependence risk.
- Ropinirole is for Parkinson's disease,
- Trihexyphenidyl is primarily used for Parkinson's disease tremor and would have significant anticholinergic side effects in this age group. Given the patient's medical history and the characteristics of her tremor, primidone is the most appropriate choice among the provided options, as it is effective for essential tremor and does not have the same level of contraindications or side effects as the other options for this patient.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Essential Tremor Treatment
The patient's symptoms, such as a bilateral hand tremor worsened by caffeine and reduced by alcohol, are consistent with essential tremor.
Pharmacotherapy Options
- Propranolol and primidone are considered "effective" agents for treating essential tremor 2, 3, 4, 5.
- The patient's condition, including coronary artery disease and hyperlipidemia, should be considered when selecting a treatment option.
- Primidone has been shown to be effective in reducing hand tremor in essential tremor patients, with efficacy comparable to propranolol 6.
Recommended Initial Pharmacotherapy
Based on the evidence, the most appropriate initial pharmacotherapy for this patient would be primidone, as it is considered an effective treatment for essential tremor and has been shown to reduce hand tremor in clinical studies 2, 3, 4, 5, 6.
Answer Choice
The correct answer is C) Primidone.