From the Guidelines
The treatment of choice for a 32-year-old trans woman with bilateral hand shaking (essential tremor) that began one year ago is propranolol, a non-selective beta-blocker, as it has been used effectively for over 40 years to treat essential tremor, as noted in a 2022 study published in Hypertension 1. The typical starting dose is 20-40 mg twice daily, which can be gradually increased to 120-320 mg daily as needed for symptom control. Propranolol works by blocking beta-adrenergic receptors, reducing the influence of the sympathetic nervous system on muscle activity, which helps decrease tremor amplitude. Some key points to consider when treating this patient include:
- Potential interactions with hormone therapy, as estrogen can affect drug metabolism, as discussed in a 2023 review of adult transgender medicine published in the Annual Review of Medicine 1
- Alternative first-line options, such as primidone, if propranolol is contraindicated or ineffective
- Non-pharmacological approaches like avoiding caffeine, getting adequate sleep, and reducing stress as important adjuncts to medication
- Referral to a neurologist for consideration of additional therapies, such as topiramate, gabapentin, or botulinum toxin injections, if tremors significantly impact daily activities despite medication. Treatment success should be monitored by improvement in functional abilities and reduction in tremor severity.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Treatment Options for Essential Tremor
The treatment of choice for bilateral hand shaking, also known as essential tremor (ET), in a 32-year-old trans woman who has been experiencing symptoms for one year is primarily symptomatic 2.
Medication Therapy
- Medications such as propranolol and primidone are considered effective agents for treating ET 3.
- Other medications like topiramate, atenolol, and alprazolam are probably effective, while nimodipine, nadolol, and clonazepam are possibly effective 3.
- Beta blockers, anticonvulsants, benzodiazepines, and carbonic anhydrase inhibitors can also be used to treat ET 4.
Alternative Therapies
- For patients who do not respond adequately to medical therapy, deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus is an alternative therapy 2, 3, 5.
- Botulinum toxin injections may be effective in reducing limb tremor, but may cause dose-dependent weakness 3, 5.