What is the best course of action for managing symptoms of essential tremor and myoclonic clonic disorder in a patient currently on lisinopril and clonazepam, with a history of propranolol, mysoline, and deep brain stimulation, and considering a clonidine restart?

Management of Essential Tremor and Myoclonic Clonic Disorder with Deep Brain Stimulation and Pharmacotherapy

The best course of action is to refill the patient's clonazepam prescription and consider restarting clonidine while arranging prompt referral to a movement disorder specialist, as clonazepam is a first-line treatment for both essential tremor and myoclonic disorders, particularly when used in combination with deep brain stimulation. 1

Pharmacological Management

First-Line Medications

• Clonazepam is recommended as an effective treatment for myoclonic disorders and can be beneficial for essential tremor, especially when other treatments have failed 1
• The typical dosage range for clonazepam is 0.25-2.0 mg taken 30 minutes before bedtime, which should be continued for this patient 1
• Deep brain stimulation (DBS) has already provided significant benefit for this patient's tremor, but supplemental medication is still needed for optimal symptom control 2

Additional Medication Options

• Clonidine can be restarted as requested by the patient, as it has shown efficacy in some tremor disorders and the patient reports previous benefit 1
• For essential tremor specifically, propranolol and primidone are considered first-line agents with approximately 50% tremor reduction, but this patient has already tried propranolol with insufficient benefit 2, 3
• Mysoline (primidone) was previously tried by this patient but did not provide adequate control, supporting the need to continue clonazepam 3, 4

Special Considerations

Medication Adherence and Efficacy

• Studies show that nearly one-third of essential tremor patients discontinue their medications due to inadequate efficacy or side effects, highlighting the importance of maintaining treatments that work for this patient 5
• The combination of DBS with pharmacotherapy provides better symptom control than either treatment alone, supporting the continuation of both approaches 2, 3

Safety and Monitoring

• Regular monitoring for side effects of clonazepam is necessary, including daytime sleepiness, dizziness, cognitive impairment, and postural instability 1
• Long-term use of clonazepam has shown minimal dosage tolerance and medication abuse in patients with movement disorders 1
• Dose escalation is reportedly rare with clonazepam for movement disorders, with studies showing no significant difference between initial and final mean doses 1

Action Plan

1. Refill the clonazepam prescription at the patient's established dose 1
2. Consider restarting clonidine as the patient reports previous benefit 1
3. Arrange urgent referral to a movement disorder specialist for comprehensive management 3
4. Ensure regular follow-up to monitor medication efficacy and side effects 1
5. Maintain the deep brain stimulator as it has provided significant benefit 2

Potential Pitfalls and Caveats

• Abrupt discontinuation of clonazepam should be avoided as it can lead to withdrawal symptoms and immediate relapse of movement disorder symptoms 1
• Older patients may be more sensitive to the sedating effects of clonazepam and may require closer monitoring 1, 6
• Medication adherence is a significant concern in essential tremor, with studies showing approximately 30% of patients discontinue treatment; therefore, maintaining medications that work for this patient is crucial 5