What can be done about tremors (shaky hands) while taking Latuda (lurasidone)?

Management of Tremor (Shaky Hands) on Latuda (Lurasidone)

Tremor is a recognized extrapyramidal side effect of Latuda that requires assessment of severity and consideration of dose reduction, anticholinergic medication, or switching to an alternative agent if the tremor significantly impacts function. 1

Understanding Latuda-Induced Tremor

• Tremor is listed as a common side effect of lurasidone, particularly in the context of extrapyramidal symptoms (EPS) that occur alongside akathisia (restlessness) and muscle stiffness 1
• The FDA label specifically identifies "difficulty moving, slow movements, muscle stiffness, or tremor" as among the most common side effects in adults with bipolar depression taking lurasidone 1
• Drug-induced tremors from antipsychotics typically manifest as action tremors or parkinsonian resting tremors, depending on the mechanism 2

Initial Assessment Steps

Determine tremor characteristics:

• Assess whether the tremor occurs at rest (parkinsonian-type) or with action/posture (enhanced physiologic or essential tremor-like) 3
• Evaluate the functional impact on daily activities, quality of life, and whether it causes distress 4
• Rule out other contributing factors: caffeine intake, anxiety, thyroid dysfunction, or concurrent medications that may exacerbate tremor 2, 5

Check for other extrapyramidal symptoms:

• Look for accompanying rigidity, bradykinesia, or akathisia, which would suggest drug-induced parkinsonism 1
• Assess for tardive dyskinesia (uncontrolled movements), though this typically develops with longer-term use 1

Treatment Algorithm

Step 1: Dose Evaluation

• Consider dose reduction of lurasidone if the patient is on higher doses (80-120 mg/day), as EPS including tremor are dose-related 6
• The therapeutic range for bipolar depression is 20-120 mg/day, allowing room for downward titration while maintaining efficacy 6

Step 2: Pharmacological Management

If tremor persists after dose optimization:

• Propranolol 80-240 mg/day is the most effective first-line treatment for drug-induced tremor, with over 40 years of demonstrated efficacy 7, 3
• Propranolol works for most tremor types and is particularly useful when the tremor has characteristics of enhanced physiologic tremor 3
• Avoid propranolol in patients with chronic obstructive pulmonary disease, bradycardia, or congestive heart failure 7, 5
• Alternative beta-blockers include nadolol, metoprolol, atenolol, or timolol if propranolol is contraindicated 7

Anticholinergic agents (though not specifically mentioned in the evidence for lurasidone, these are standard for antipsychotic-induced parkinsonism based on general medical knowledge):

• Consider if parkinsonian features predominate alongside tremor
• Use cautiously due to cognitive side effects

Step 3: Medication Switch

• If tremor remains functionally limiting despite dose reduction and beta-blocker therapy, consider switching to an alternative mood stabilizer or antipsychotic with lower EPS risk 1
• Lurasidone has a favorable metabolic profile (minimal weight gain, low metabolic disturbance risk), so weigh this benefit against the tremor burden 6

Important Clinical Pitfalls

Do not dismiss the symptom:

• Tremor significantly impacts quality of life and medication adherence 4
• Patients may discontinue treatment without informing providers if side effects are not addressed 1

Monitor for progression:

• Assess for development of tardive dyskinesia, which "may not go away, even if you stop taking lurasidone" 1
• Tardive dyskinesia can start after stopping the medication 1

Avoid reinforcing anxiety:

• Tremor can be exacerbated by anxiety about the tremor itself 2
• Provide clear explanation that this is a known, manageable side effect 4

Check thyroid function:

• Lurasidone can affect thyroid function, and hypothyroidism itself can cause tremor 1, 5
• Monitor thyroid-stimulating hormone, especially in patients with known hypothyroidism 1

Monitoring During Treatment

• Regularly assess tremor severity using objective measures (observation of outstretched hands) 8, 5
• Monitor for orthostatic hypotension if starting propranolol, as lurasidone already carries risk of decreased blood pressure 1
• Watch for beta-blocker side effects: fatigue, depression, dizziness, hypotension, sleep disturbances 5
• Continue monitoring for other EPS symptoms and metabolic parameters 1, 6