From the Guidelines
No, propranolol 100mg PO QID x 14 days is not a reasonable starting dose for presumed essential tremor in an elderly patient. This dose is too high to start with and could cause significant adverse effects, as indicated in the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. For elderly patients with essential tremor, a more appropriate starting dose would be propranolol 10-20mg PO BID or TID, with gradual titration based on response and tolerability.
The recommended initial daily dose of propranolol is 30–60 mg in divided or single dose with long-acting formulations, as stated in the guideline 1. The maximum daily dose should generally not exceed 320mg total per day, divided into multiple doses. Elderly patients are more sensitive to beta-blockers and at higher risk for side effects including hypotension, bradycardia, fatigue, and confusion. Starting with a lower dose allows for assessment of tolerability while still providing therapeutic benefit.
Some key considerations when prescribing propranolol to elderly patients include:
- Monitoring for heart rate, blood pressure, and symptoms of hypoglycemia, especially if they have diabetes, as propranolol can mask these symptoms
- Taking the medication with food to enhance absorption and reduce gastrointestinal side effects
- Avoiding use in patients with contraindications such as asthma, COPD, heart block, or heart failure
- Considering alternative medications like primidone if propranolol is not suitable. The guideline highlights the importance of cautious use of beta blockers in certain patient populations, including those with reactive airway disease, decompensated systolic heart failure, and hypotension 1.
From the Research
Essential Tremor Treatment
- Essential tremor is a common movement disorder characterized by kinetic and postural tremor, and propranolol is one of the first-line treatments for this condition 2, 3, 4.
- The recommended dosage of propranolol for essential tremor is not explicitly stated in the provided studies, but it is classified as clinically useful for limb tremor 5.
- Propranolol and primidone are considered first-line treatments for essential tremor, and they can be used synergistically 3, 4.
- The dosage of 100mg PO QID X 14 days may be a reasonable starting dose for propranolol in an elderly patient with presumed essential tremor, but the studies do not provide specific guidance on the optimal dosage or duration of treatment for this population.
Considerations for Elderly Patients
- Elderly patients may be more susceptible to the adverse effects of propranolol, such as hypotension, bradycardia, and exacerbation of asthma or chronic obstructive pulmonary disease 2, 5.
- The studies suggest that propranolol is effective in reducing limb tremor in patients with essential tremor, but the evidence for its use in elderly patients is limited 2, 5, 3, 4.
- Topiramate is another option for treating essential tremor, and it has been shown to be effective in reducing tremor severity, but it may have adverse effects such as cognitive impairment, fatigue, and weight loss 6.
Pharmacological and Surgical Treatments
- Propranolol, primidone, and topiramate are considered effective pharmacological treatments for essential tremor, while deep brain stimulation and focused ultrasound are considered effective surgical treatments 2, 5, 3, 4.
- The choice of treatment for essential tremor should be individualized based on the patient's symptoms, medical history, and response to treatment, as well as the potential risks and benefits of each treatment option 2, 5, 3, 4.