How to manage essential tremor in a patient taking lithium carbonate (450 mg twice daily) and Olanzapine (5 mg once daily)?

From the Guidelines

Managing essential tremor in a patient taking lithium carbonate (450 mg twice daily) and olanzapine (5 mg once daily) should start with considering propranolol as a first-line treatment option, given its established efficacy for over 40 years, as noted in a 2022 study published in Hypertension 1. When evaluating the patient's current medication regimen, it's crucial to assess whether the tremor is a side effect of lithium or olanzapine, as both can contribute to or exacerbate tremors.

• If the tremor is medication-induced, consider reducing the dose of lithium or olanzapine if clinically feasible, or explore alternative medications with a lower risk of causing tremors.
• For the treatment of essential tremor itself, propranolol can be initiated at a dose of 20-40 mg twice daily, with adjustments as needed and under close monitoring for potential interactions with olanzapine. Key considerations include:
• Monitoring lithium levels closely to maintain the lowest effective concentration, thereby minimizing the risk of tremor.
• Exploring non-pharmacological strategies such as avoiding caffeine, employing stress reduction techniques, and occupational therapy to complement medication management.
• Considering alternative medications like primidone, topiramate, or gabapentin if propranolol is not suitable or effective.
• Referral to a neurologist for advanced treatments, including botulinum toxin injections or deep brain stimulation, may be necessary for severe or treatment-resistant cases. The primary goal is to achieve a balance between controlling psychiatric symptoms and managing tremor, all while minimizing adverse effects, as supported by the most recent and highest quality evidence available, such as the study published in 2022 1.

From the FDA Drug Label

Essential Tremor In a 2 week, double-blind, parallel, placebo-controlled study of 9 patients with essential or familial tremor, propranolol, at a dose titrated as needed from 40 mg to 80 mg three times a day reduced tremor severity compared to placebo The patient is taking lithium carbonate and Olanzapine, but the provided drug label is for propranolol.

• Management of essential tremor in this patient could involve considering propranolol as a potential treatment option, as it has been shown to reduce tremor severity in patients with essential or familial tremor 2.
• However, it is crucial to consider potential interactions between propranolol and the patient's current medications, lithium carbonate and Olanzapine, before initiating treatment.
• The patient's current medications do not appear to be directly addressed in the provided label, and therefore, caution is advised when considering the addition of propranolol to their treatment regimen.

From the Research

Management of Essential Tremor

The management of essential tremor in a patient taking lithium carbonate (450 mg twice daily) and Olanzapine (5 mg once daily) involves several considerations:

• The patient's current medications, lithium carbonate and Olanzapine, are not typically used as first-line treatments for essential tremor 3, 4.
• The treatment of essential tremor usually involves medications such as primidone, propranolol, or other beta-adrenoceptor antagonists, which can be effective in approximately 50% of patients 3, 4.
• If the patient's tremor is disabling, treatment should be initiated with either primidone or propranolol, and if necessary, the medications can be used in combination 3.
• Other medications that may be helpful include benzodiazepines, gabapentin, or topiramate, although the evidence for their efficacy is limited 3, 5.
• In some cases, botulinum toxin injections or deep brain stimulation of the thalamus may be considered, especially if the patient has disabling head or voice tremor or if medications are ineffective 3, 6, 7.

Treatment Options

Some possible treatment options for the patient include:

• Adding primidone or propranolol to the patient's current medication regimen, if not contraindicated 3, 4.
• Considering alternative medications such as topiramate or gabapentin, if the patient's tremor is not adequately controlled with primidone or propranolol 3, 5.
• Referring the patient to a specialist for evaluation and consideration of botulinum toxin injections or deep brain stimulation surgery, if medications are ineffective or cause significant side effects 3, 6, 7.

Monitoring and Follow-up

It is essential to monitor the patient's response to treatment and adjust the medication regimen as needed:

• Regular follow-up appointments should be scheduled to assess the patient's tremor severity and adjust the treatment plan accordingly 7.
• The patient should be educated on the potential benefits and risks of each treatment option and involved in the decision-making process 3, 4.