Management of Levosulpiride-Induced Tremors
Discontinue levosulpiride immediately and initiate propranolol 10-40 mg every 6 hours for symptomatic tremor control while the drug clears from the system. 1, 2
Immediate Action Required
Stop levosulpiride immediately upon recognition of tremor, as this is a dopamine D2 receptor antagonist-induced extrapyramidal side effect that can progress to more severe movement disorders including dystonia and Parkinsonism. 3, 4
Rule out other contributing factors before attributing tremor solely to levosulpiride: check thyroid function, assess caffeine intake, review all concurrent medications (particularly other dopaminergic agents, SSRIs, or stimulants), and correct any electrolyte abnormalities (potassium, magnesium). 2, 5
Symptomatic Treatment Strategy
Propranolol is the first-line medication for drug-induced tremor control with over 40 years of demonstrated efficacy, starting at 10-40 mg every 6 hours and titrating up to 80-240 mg/day as needed. 2, 5, 6
Propranolol Contraindications to Screen For:
- Bradycardia (heart rate <60 bpm) 2
- Decompensated heart failure 2
- Asthma or severe COPD 2, 6
- Hypotension 5
Alternative Beta-Blockers if Propranolol Not Tolerated:
- Metoprolol, nadolol, or atenolol can be substituted, though evidence is strongest for propranolol. 2, 6
Second-Line Options if Beta-Blockers Contraindicated:
- Gabapentin may provide moderate benefit for medication-induced tremor. 2
- Benzodiazepines (clonazepam) can be reserved for situational use or refractory cases, but carry dependence risk and should not be first-line. 2, 6
Critical Monitoring Points
Monitor for orthostatic hypotension when initiating propranolol, particularly in elderly patients. 5
Watch for beta-blocker side effects: fatigue, depression, dizziness, sleep disturbances, and in diabetic patients, masking of hypoglycemia symptoms. 2, 5
Assess tremor severity objectively by observing outstretched hands at each visit. 5
Allow 4-8 weeks for full therapeutic trial of any symptomatic medication before declaring treatment failure and switching agents. 2
Expected Recovery Timeline and Prognosis
Recovery from levosulpiride-induced tremor is variable and often incomplete. In a case series of 7 patients with levosulpiride-induced dystonia, all patients showed at least 50% improvement after drug discontinuation, but none had complete recovery at mean follow-up of 5.5 months. 3 This underscores the importance of early recognition and immediate discontinuation.
- Tremor may persist for 1-4 weeks after drug discontinuation even with treatment. 2
- Some patients may develop persistent symptoms, particularly if cerebellar involvement occurs. 2
Important Clinical Caveats
Do not use calcium channel blockers (verapamil, diltiazem) for tremor management—they are ineffective for medication-induced tremor and contraindicated in patients with myocardial dysfunction. 2
Avoid combining multiple CNS-active medications that could worsen tremor or cause drug-drug interactions; review the complete medication list to eliminate unnecessary agents. 2
In patients with renal or hepatic impairment, adjust doses accordingly and avoid medications with active metabolites that accumulate. 2
Switching Prokinetic Therapy
Since levosulpiride was prescribed as a prokinetic agent for functional dyspepsia, consider alternative treatments per British Society of Gastroenterology guidelines: 1
- First-line alternatives: PPIs (strong evidence, well-tolerated) or H2-receptor antagonists 1
- Alternative prokinetics with lower extrapyramidal risk: acotiamide, itopride, mosapride, or tegaserod (though availability varies by region) 1
- Avoid other dopamine antagonists (metoclopramide, domperidone) as they carry similar extrapyramidal side effect risk 1
Patient Counseling Essential
Tremor significantly impacts quality of life and medication adherence—patients may discontinue treatment without informing providers if side effects are not addressed. 5 Provide clear explanation that the tremor is medication-induced, will improve with discontinuation, and symptomatic treatment is available while the drug clears.