What are alternative treatments for tremors besides Ingrezza (valbenazine)?

Alternative Treatments for Tremors Besides Ingrezza (Valbenazine)

For patients requiring treatment for tremors, propranolol and primidone are the first-line pharmacological options, with approximately 50% efficacy in controlling tremors. 1

First-Line Pharmacological Options

Beta-Blockers

• Propranolol: 40 mg twice daily, maximum 240 mg daily
  • Most established beta-blocker for tremor management
  • Particularly useful for stress/anxiety-induced tremors
  • Can be used as needed during periods of anticipated tremor exacerbation

Anticonvulsants

• Primidone: Start at low doses (12.5-25 mg) and gradually increase
  • Can be used alone or in combination with propranolol for enhanced efficacy
  • Side effects include sedation and unsteadiness, especially during initiation

Second-Line Pharmacological Options

Alternative Beta-Blockers

• Metoprolol: Option for patients with respiratory concerns
• Atenolol: Fewer central nervous system effects
• Nadolol: Alternative for patients with contraindications to propranolol

Other Anticonvulsants

• Topiramate: Effective alternative with evidence supporting its use
• Gabapentin: 300-2400 mg daily (divided into three doses)
  • Particularly beneficial for patients with comorbid neuropathic pain

Benzodiazepines

• Clonazepam: Useful particularly when anxiety is a component
  • Caution with long-term use due to dependence potential

Treatment Algorithm for Tremors

1. Initial Assessment:

   • Determine if tremor causes functional disability
   • If minimal impact, consider non-pharmacological approaches first

2. First-Line Treatment:

   • Start with either propranolol or primidone monotherapy
   • If partial response, consider combination therapy

3. Inadequate Response:

   • Add or switch to alternative agents (gabapentin, topiramate)
   • Consider benzodiazepines for short-term or intermittent use

4. Refractory Tremor:

   • Consider surgical options for medication-refractory cases:
     • Deep brain stimulation (DBS): ~90% efficacy, preferred for bilateral procedures
     • MR-guided focused ultrasound thalamotomy: For unilateral treatment

Special Considerations

Head or Voice Tremor

• Botulinum toxin injections into affected muscles may provide relief
• Hand injections less commonly used due to risk of weakness

Cautions with Beta-Blockers

• May mask hypoglycemia symptoms in diabetic patients
• Can cause bronchospasm in patients with asthma or COPD
• Start at lower doses in elderly patients

Non-Pharmacological Approaches

• Rhythm-based techniques: Superimposing alternative voluntary rhythms
• Muscle relaxation strategies: Preventing muscle co-contraction
• Distraction techniques: Using gross rather than fine movements

Treatment Efficacy

• Current pharmacological treatments improve tremor in approximately 50% of patients
• Surgical options provide adequate tremor control in about 90% of medication-refractory cases
• No current treatments slow disease progression or provide a cure

Remember that tremor management should be initiated when the tremor causes functional disability, with the goal of improving quality of life and reducing disability 1, 2.