Is propranolol (Propranolol) 10 milligrams (mg) orally (PO) four times a day (QID) for 14 days a reasonable starting dose for presumed essential tremor in an elderly patient?

From the Guidelines

Propranolol 10mg PO QID for 14 days is not a reasonable starting dose for presumed essential tremor in an elderly patient, as the recommended initial dose is 30-60 mg in divided or single dose with long-acting formulations, according to the 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia 1. This guideline suggests that propranolol can be initiated at a dose of 30-60 mg daily, which may be divided into multiple doses or given as a single dose with long-acting formulations. When treating essential tremor, particularly in elderly patients, it is crucial to consider the potential for adverse effects such as hypotension, bronchospasm, and bradycardia, as outlined in the guideline 1. Key considerations for initiating propranolol in an elderly patient with presumed essential tremor include:

• Starting with a dose within the recommended range to minimize side effects
• Monitoring for potential adverse effects, including bradycardia, hypotension, fatigue, and bronchospasm
• Adjusting the dose based on the patient's response and tolerability
• Being aware of the precautions and interactions listed in the guideline, such as avoiding use in patients with AV block greater than first degree or SA node dysfunction, decompensated systolic heart failure, hypotension, reactive airway disease, and severe renal dysfunction 1. Given the potential for elderly patients to be more sensitive to beta-blocker side effects, careful dose titration and monitoring are essential. The mechanism of action of propranolol in reducing tremor amplitude involves blocking peripheral beta-adrenergic receptors, particularly in skeletal muscle. After the initial treatment period, evaluating the effectiveness of the dose and considering adjustments as needed is crucial, with some patients eventually requiring higher doses for optimal tremor control.

From the Research

Dosage of Propranolol for Essential Tremor

• The dosage of propranolol for essential tremor is not explicitly stated in the provided studies as a specific starting dose of 10mg PO QID X 14 days 2, 3, 4, 5, 6.
• However, the studies suggest that propranolol is an effective treatment for essential tremor, with dosages ranging from 80 to 160 mg/d in one study 6.
• The American Academy of Neurology's practice parameter for therapies for essential tremor recommends propranolol as a first-line treatment, but does not specify a starting dose 4.
• Another study classified propranolol as clinically useful for essential tremor, but only for doses higher than 200 mg/day 3.

Considerations for Elderly Patients

• When treating elderly patients with propranolol for essential tremor, it is essential to consider the potential for adverse reactions and side effects, such as those reported in one study where 17% of patients taking propranolol experienced significant chronic side effects 6.
• The dosage of propranolol may need to be adjusted based on the patient's response and tolerance to the medication.
• It is crucial to weigh the potential benefits of propranolol against the possible side effects, especially in elderly patients who may be more susceptible to adverse reactions 2, 5.