Essential tremor: what are the treatment options?

Essential tremor is a common neurologic problem. It should be differentiated from secondary causes of tremor and Parkinson disease.

Impact of essential tremor

Essential tremor causes motor dysfunction (e.g. a dentist may have to quit his/her job). However, more importantly, the tremor can have a psychological impact on the patient, especially since it usually gets worse in social situations.

Diagnosis

Essential tremor is a clinical diagnosis. A thorough review of the medical history and medication exposures is a good start. Laboratory and imaging tests may be ordered to rule out a secondary cause.

Treatment

The two first-line agents in drug therapy for essential tremor are:

- nonselective beta-blocker propranolol (Inderal)
- antiepileptic primidone (Mysoline)

They can be used alone or in combination.

Severe, resistant, or atypical cases should be referred to a specialist. Botulinum toxin injection and deep brain stimulation are reserved for resistant tremor or for patients who do not tolerate drug therapy.

Dr. Young from Swedish Medical Center discusses some of the new treatments for essential tremor in this video:



References:

Essential tremor: Choosing the right management plan for your patient. CCJM, 2011.

Treatment Options for Osteoporosis

I selected a few excerpts from a patient information review in the New York Times:

What is osteoporosis

Osteoporosis is defined as having a bone mineral density T score of minus 2.5 or lower. Lesser degrees of bone loss, known as osteopenia, may not benefit from drug therapy.

Bisphosphonates

The first drug licensed to counter osteoporosis, Fosamax, is now available generically as alendronate, which can be taken once a day or, at a higher dose, once a week. A reluctance on the part of many patients to adhere to a daily or weekly regimen led to the development of Boniva (ibandronate), administered by an intravenous injection every three months. To further simplify the frequency of administration, Reclast (zoledronic acid) was developed as a once-a-year intravenous treatment.

Actonel, alendronate and Boniva have been shown in three-year studies of postmenopausal women to reduce vertebral fractures by 41-50%, and less for other kinds of fractures.

A three-year study of Reclast found it to be somewhat more effective, with a 70 percent reduction in vertebral fractures, 41 percent in hip fractures and 25 percent in other fractures in postmenopausal women with osteoporosis.

Side Effects of Bisphosphonates

In a large study of Reclast, there was also a worrisome increase in atrial fibrillation — an irregular heart rhythm — not known to occur with other bisphosphonates.

Low-trauma fracture with a delay in healing or complete failure may occur after many years on bisphosphonates.

These side effects have prompted a warning that after five years on bisphosphonates, people should take a break from the drugs for at least a year.

Evista (raloxifene)

Evista (raloxifene) has an added advantage of reducing the risk of breast cancer, but the disadvantage of increasing the risk of deep vein blood clots.

Calcitonin

Somewhat less effective at reducing vertebral fractures is calcitonin, a naturally occurring hormone sold as Fortical and Miacalcin.

Forteo (teriparatide)

Finally, there is the bone-building drug Forteo (teriparatide), which must be self-injected once a day. This human parathyroid hormone can reduce vertebral fractures by 65 percent and other fractures by 53 percent within 18 months in patients with osteoporosis.

Denosumab

Under study is an entirely new bone drug, denosumab, a human monoclonal antibody. The drug inhibits a receptor that activates cells called osteoclasts that break down bone. In a large three-year study, denosumab, given by injection every six months to postmenopausal women with osteoporosis, reduced vertebral fractures by 68 percent and hip fractures by 40 percent.

References:
Options for Bone Loss, but No Magic Pill. NYT, January 4, 2010.
Denosumab is a monoclonal antibody that reduces fractures in osteoporosis
Image source: Flickr, Creative Commons license.

Treatment options for migraine patients

From the NYTimes:

"Migraines are notoriously tricky to treat. Those who suffer from these disabling headaches often try a dozen or so medications before they find something that works.

“What might be a miracle drug for one person could be a dud for another.” Be prepared for a multi-tiered approach.

Doctors typically prescribe a triptan drug or an ergot-related drug to help people control infrequent migraine attacks. There are 7 types of triptans. The best-seller Imitrex (sumatriptan) is available in an affordable generic version (the chemical formula is shown above). Triptans are far more popular, but many people who do not respond well to triptans do well with the ergots, such as D.H.E. (dihydroergotamine), Dr. Saper said.

If you have migraines at least weekly your doctor may prescribe a preventative medicine. “Prescription preventatives are grossly underutilized. They can be extremely effective for some people.”

Preventive medicines, taken every day, include antiseizure drugs, beta blockers and tricyclic antidepressants."

References:
Migraines Force Sufferers to Do Their Homework
http://www.nytimes.com/2010/01/30/health/30patient.html
NYTimes, Patient Voices: Migraine
http://www.nytimes.com/interactive/2009/12/15/health/healthguide/TE_migraine.html

Triptans for Migraine: How should triptans be used? NEJM blog, 2010.

Image source: Sumatriptan, Wikipedia, public domain.

Related:

Migraine with aura is an independent risk factor for cardiovascular and all cause mortality in men and women http://goo.gl/kAxc

Migraine with aura might, in addition to ischaemic events, also be a risk factor for haemorrhagic stroke http://goo.gl/GQvf

Review: Which drugs are effective for preventing migraine headache? http://goo.gl/WXfEl

Migraine headaches are more common in patients with allergic rhinitis - immunotherapy decreases headache frequency http://goo.gl/XEIBq

Pharmacological prevention of migraine - BMJ review http://goo.gl/Q5K2m