What medications are used to manage cerebellar tremor?

Pharmacologic Management of Cerebellar Tremor

For cerebellar tremor, the most effective medication options are propranolol or primidone for essential tremor with cerebellar features, topiramate for tremor associated with multiple sclerosis or other cerebellar dysfunction, and isoniazid specifically for cerebellar tremor in multiple sclerosis patients. 1, 2, 3

Drug-Induced Cerebellar Tremor: Prevention and Cessation

The most critical intervention for drug-induced cerebellar syndrome (such as from high-dose cytarabine) is immediate discontinuation of the causative agent rather than attempting symptomatic treatment with tremor medications. 4, 5

• Acute cerebellar syndrome from chemotherapy agents (high-dose cytarabine, bortezomib, rituximab, trastuzumab) manifests as dizziness, ataxia, dysarthria, vertigo, and cerebellar eye movement disorders typically 2-5 days after treatment initiation 4
• No specific preventive measures or causative treatments are available beyond stopping the offending drug 4, 5
• Avoiding very high doses of cytarabine, especially in patients with renal impairment, may reduce incidence 4, 5
• Recovery is uncertain and ranges from complete remission to persistent disabling ataxia 4, 5

Primary Cerebellar Tremor: Medication Options

First-Line Agents

Propranolol or primidone should be considered as first-line therapy for cerebellar tremor, particularly when essential tremor features are present. 1

• These agents are established treatments that may be amenable to cerebellar-type tremors 1
• Propranolol enhances GABAergic neurotransmission, addressing the underlying Purkinje cell dysfunction characteristic of cerebellar tremor 6

Topiramate for Cerebellar Tremor

Topiramate shows promising efficacy for cerebellar tremor, particularly in multiple sclerosis patients, with dosing ranging from 25 mg twice daily to 100 mg twice daily. 2, 3

• In an open-label trial, topiramate reduced mean tremor amplitude by 20-75% compared to baseline 2
• Clinical scores for postural and kinetic tremor significantly decreased (P<0.05), with improvements in writing, eating, and drawing 2
• A case report demonstrated marked and lasting improvement of both tremor and ataxia in a multiple sclerosis patient on 150 mg daily over 2 years 3

Critical caveat: Topiramate must be titrated slowly due to significant adverse effects including sedation, cognitive impairment, increased aggressiveness, and asthenia. 2

• In the trial, 4 of 9 patients discontinued due to adverse effects 2
• The range and frequency of adverse events may limit clinical usefulness despite efficacy 2

Isoniazid for MS-Related Cerebellar Tremor

Isoniazid may specifically control cerebellar tremor associated with multiple sclerosis. 1

• This represents a targeted option when cerebellar tremor occurs in the context of demyelinating disease 1

CAR T Cell Therapy-Related Tremor

For tremor occurring as part of CAR T cell-related encephalopathy syndrome (CRES):

• Tremor is graded as part of neurological toxicity assessment using CARTOX-10 scoring 4
• Management focuses on supportive care, avoiding CNS depressants, and treating the underlying CRES rather than tremor-specific medications 4
• Low-dose lorazepam (0.05 mg/kg, maximum 1 mg per dose IV every 8 hours) or haloperidol (0.05 mg/kg, maximum 1 mg per dose IV every 6 hours) can be used cautiously for agitation with careful monitoring 4
• Anti-IL-6 therapy and corticosteroids target the underlying syndrome when CRES occurs with cytokine release syndrome 4

Treatment Algorithm

1. Identify etiology: Determine if tremor is drug-induced (chemotherapy, immunotherapy) versus primary cerebellar disease 4, 1

2. If drug-induced: Immediately discontinue causative agent; no specific tremor medications recommended 4, 5

3. If primary cerebellar tremor:

   • Start with propranolol or primidone as first-line 1
   • Consider topiramate if MS-related or if first-line agents fail, starting at 25 mg twice daily and titrating slowly to minimize adverse effects 2, 3
   • Use isoniazid specifically for MS-associated cerebellar tremor 1

4. Monitor closely: Assess for adverse effects, particularly with topiramate (cognitive impairment, sedation) 2