You may worry it’s a tremor from Parkinsons, but often it’s not. Essential tremor (ET) is the most common tremor disorder in adults and often affects patients’ ability to write and eat. The head and voice are commonly affected, and many of you remember Katherine Hepburn’s essential tremor as the classic example. Once your doctor has told you that your tremor is ET and not something else, you will wonder what your options for treatment are. Here you go:
• Propranolol (Inderal) is the medication used most frequently and successfully to treat ET. Propranolol is known as a beta-blocker and is the only medication approved by the FDA to treat ET. Your dose will be gradually increased to achieve optimal response, with a close eye on blood pressure while you are taking it. Propranolol is most effective for upper limb tremor and less effective for head and voice tremors.
• Primidone (Mysoline) is also commonly used for ET and may be added to propranolol as dual therapy. Primidone is related to phenobarbital and is most effective for hand tremor. It reduces tremor amplitude by 60-70%.
• Unfortunately, 30% to 50% of patients will not respond to either primidone or propranolol, and that’s where it gets tricky because though other options have been studied, they don’t work all that well.
• What doesn’t work? Keppra (levetiracetam), a seizure medication, was tested for essential tremor and doesn’t work. Sibelium (flunarizine) should also not be considered for treatment of ET. Though not completely ruled out yet, we don’t have any evidence that Lyrica or Zonegran help for ET either.
First, let’s talk about what makes Glynase and Diabeta similar. Both of these medications are used in type 2 diabetes to improve glycemic control and lower blood sugar levels, both are 2nd generation drugs in the sulfonylurea class and work by telling the pancreas to release more insulin, and both have a form of glyburide as the active ingredient.
So, how does Glynase differ from Diabeta?
Glynase is micronized glyburide which has a different duration of action, absorption, and dosage than its nonmicronized counterpart, Diabeta or Micronase (regular glyburide). Micronized glyburide contains smaller particles that allow the medication to be absorbed better by the body—therefore, lower doses can be used.
How are these medications taken?
What if you have a SULFA allergy?
A reaction is possible with any of the sulfonylureas, however, remember, glyburide is a 2nd generation sulfonylurea. Reactions occur more frequently with the 1st generation sulfonylurea, chlorpropamide (Diabinese).
Can these medications be substituted for one another?
Good news for multiple sclerosis (MS) patients taking Copaxone (glatiramer acetate)—the FDA has approved a new three-times-weekly dose. The new dose will still be a subcutaneous injection, but will have a higher concentration at 40 mg/ml. Copaxone is currently available as 20 mg/ml injection, taken once daily. The new strength is approved in addition to the lower daily dose, and will not replace it.
The approval was based on a study that showed the 40 mg/ml dose given three times weekly reduced relapse rates by as much as 1/3 at twelve months, compared with a placebo.
The three-times-weekly 40 mg/ml strength of Copaxone will be available in pharmacies within days. There are several other new MS treatments recently approved, so you may want to discuss with your doctor which option is best for you.
Patients not taking their medications properly, noncompliance, is a complex issue with huge repercussions. For more information on the effects, see my previous post, The Epidemic of Noncompliance.
Reasons for not taking medications vary from patient to patient but the pattern for years has been that folks who are the most noncompliant are those who need their meds the most. This includes those with chronic conditions who need to take a medication their whole life, and those in the first 6 months of their treatment. Let’s breakdown the process to find the problems, and what you can do:
1. Getting the right prescription
Getting a new or refill authorization to the pharmacy should work smoothly but often it doesn’t. Now that more physicians are prescribing electronically this should be easier.
This is what Goodrx is all about. Whether it’s because you lost your job, your medication isn’t on formulary of it just simply costs too much, many of you can’t afford your meds. Know that you can save money on generic options, pill splitting, and coupons—ask, please ask, your doctor about a change in medications if it’s too expensive. Please don’t just stop your meds. Having said this, studies done on patients who were given their cholesterol meds for free improved compliance only slightly. So it’s not just cost.
3. Side effects
Twenty percent of folks who stop taking their meds do so because of a perceived side effect. Many of you don’t tell your doctor when you’ve stopped. Please talk to your doctor about what you perceive as a side effect, as there is likely an easy solution or another good option for treatment.
4. The doctor’s role
With patients in their doc’s office only a few hours a year, if even that, many slip quietly off of their medication regimens. More importantly, you want more information about a new medication you will be taking than your doctor gives you. The average time a doctor spends talking about all aspects of a newly prescribed medication is 49 seconds. Clearly a doctors style of communication can help here and when a doctor “shares authority” and offers you a suggestion of a new medication but ultimately leaves the decision to you, compliance is improved.
This is where we have to get better. In many surveys it is the number one reason for people not taking their meds, with ¼ of people surveyed saying they don’t take their meds because they forget. This is worse if you are taking several meds. Shame on us, we can remember this.
6. You have no symptoms
Patients who don’t “feel” anything from their condition, as with high cholesterol or high blood pressure, are the ones who don’t tend to take their meds. Know that this is why these conditions are called “silent killers.” You need to take your meds even when you don’t feel bad.
7. Fragmented care
For those of you who see many specialists (a cardiologist, endocrinologist, rheumatologist) who each prescribe their own medications, getting refills can be a nightmare. As a primary care doctor I don’t mind taking over the refill authorizations on medications my patients have been on for months even if initiated by another doctor, but that’s a discussion you should have with your doc.
What did I miss?
Help physicians understand why patients, particularly with chronic conditions, don’t take their medications as prescribed. We know from surveys of doctors from coast to coast that we all feel frustrated by it, and ⅓ of doctors say it affects their ability to provide optimal care. Why should you take your medications? As our former Surgeon General once said: “Drugs don’t work in people who don’t take them.”
- In the United States, over 50% of medications prescribed are taken incorrectly or not taken at all.
- One third of folks with chronic conditions (diabetes, high blood pressure, high cholesterol) don’t fill their new prescriptions at all.
- Poor compliance (not taking your meds) accounts for 33 – 70% of drug-related adverse events that result in hospital admissions. I see this all the time.
- Forty percent of nursing home admissions are associated with poor compliance with medication.
- Poor medication compliance is implicated in over 125,000 US deaths per year. What?!
- Poor compliance is estimated to cost the US Healthcare system $290 billion a year.
Those who do:
- Compared with patients who follow instructions, patients who don’t take their meds have a 5 times higher risk of death if they have high blood pressure—2.8 times higher if they have high cholesterol.
- The rate of noncompliance hasn’t changed over the past couple decades. So we aren’t getting any better at taking meds, despite the fact that newer medication regimens are known to save lives for folks with heart disease, high cholesterol, diabetes and high blood pressure, and have better side effect profiles.
- Heartbreaking (literally) for physicians is the number of folks with cardiac conditions who don’t take their meds.
- Within two years after a heart attack, only half of patients were taking their heart meds (beta blockers, ace inhibitors, etc).
- As an example, taking a beta blocker (metoprolol, carvedilol, etc) after a heart attack reduces your risk of death by 20 – 30%. Do we hear this? Taking a pill every day will reduce your risk of death by ⅓. Please take it.
- Folks, heart disease is the number one cause of death in adults. These medications have been proven to save lives after heart attack, why don’t we take them?