Propranolol Dosing for Tremor Treatment
For essential tremor, propranolol should be dosed at 120-240 mg daily in divided doses, with most patients responding well to 120 mg per day. 1, 2, 3
Initial Dosing and Titration
- Start with 40 mg three times daily (120 mg total daily dose) for essential tremor 4
- If inadequate response after 3 months at 120 mg daily, consider increasing up to 240 mg daily maximum 2, 3
- Therapeutic effect can be observed at relatively low plasma concentrations (below 40 ng/ml), which are typically achieved with daily doses of 120-240 mg 3
Monitoring and Response Assessment
- Improvement in tremor is most pronounced in the upper extremities and can be assessed through handwriting quality and manual dexterity tests 1
- Expect significant tremor reduction in approximately 70% of patients (8 out of 11 patients showed improvement in clinical trials) 1, 2
- Monitor for response within hours of first dose, as effects can be observed quickly but may diminish within 4 hours with single dosing 4
Duration of Treatment
- Long-term therapy is often required, with treatment response potentially maintained for up to 4 years 2
- Response tends to decrease with increasing age - patients under 55 years show better response than those over 60 years 2
- Consider a 3-month trial period to assess efficacy before determining long-term treatment plan 2
Adverse Effects and Precautions
- Chronic side effects occur in approximately 17% of patients on long-term propranolol therapy 5
- Tolerance to drug effect may develop in about 12.5% of patients with chronic treatment 5
- Contraindications include heart block, asthma, decompensated heart failure, and hypotension 6
- Baseline cardiovascular assessment is recommended before initiating propranolol 6
- Monitor for potential adverse effects including hypotension, bradycardia, and bronchospasm 6
- Avoid abrupt discontinuation to prevent rebound hypertension or tachycardia 6
Treatment Failure Considerations
- Approximately 30% of patients may not benefit from propranolol treatment 5
- If no significant response is seen after 3 months at 120 mg/day, consider decreasing the dose and then discontinuing the medication 2
- Alternative treatments such as primidone may be considered for non-responders, though primidone has a higher rate of acute adverse reactions (32% vs 8% with propranolol) 5