Drugs used in essential PIRACETAM

4.9.3 Drugs used in essential PIRACETAM

tremor, chorea, tics, and Indications adjunctive treatment of cortical myoclo-

related disorders nus

Cautions avoid abrupt withdrawal; elderly; haemosta- sis, major surgery, or severe haemorrhage; renal Tetrabenazine is mainly used to control movement

impairment (avoid if creatinine clearance less than disorders in Huntington’s chorea and related disorders.

20 mL/minute; Appendix 3) It may act by depleting nerve endings of dopamine. It

Contra-indications cerebral haemorrhage; hepatic has useful action in only a proportion of patients and its

impairment; pregnancy; breast-feeding use may be limited by the development of depression.

Side-effects weight gain, nervousness, hyperkinesia; Haloperidol may be useful in improving motor tics and

less commonly drowsiness, depression, asthenia,; also symptoms of Tourette syndrome and related choreas.

reported abdominal pain, nausea, vomiting, diarrhoea, Pimozide [unlicensed indication] (see section 4.2.1 for

headache, anxiety, confusion, hallucination, vertigo, CSM warning), clonidine [unlicensed indication] (sec-

ataxia, insomnia, and rash tion 4.7.4.2), and sulpiride [unlicensed indication] (sec-

Dose

tion 4.2.1) are also used in Tourette syndrome. Trihex- . Initially 7.2 g daily in 2–3 divided doses, increased yphenidyl (benzhexol) (section 4.9.2) in high dosage

according to response by 4.8 g daily every 3–4 days to can also improve some movement disorders; it is some-

max. 20 g daily (subsequently, attempts should be times necessary to build the dose up over many weeks,

made to reduce dose of concurrent therapy); CHILD to 20 to 30 mg daily or higher. Chlorpromazine and

under 16 years not recommended haloperidol are used to relieve intractable hiccup (sec-

Oral solution Follow the oral solution with a glass of water tion 4.2.1).

(or soft drink) to reduce bitter taste. Propranolol or another beta-adrenoceptor blocking

Nootropil c (UCB Pharma) A drug (section 2.4) may be useful in treating essential

Tablets , f/c, scored, piracetam 800 mg, net price 90- tremor or tremors associated with anxiety or thyrotoxic-

tab pack = £14.69; 1.2 g, 60-tab pack = £13.71. osis. Propranolol is given in a dosage of 40 mg 2 or 3

Label: 3

times daily, increased if necessary; 80 to 160 mg daily is Oral solution , piracetam, 333.3 mg/mL, net price usually required for maintenance.

300-mL pack = £20.39. Label: 3 Primidone (section 4.8.1) in some cases provides relief

from benign essential tremor; the dose is increased slowly to reduce side-effects.

RILUZOLE

entral C

Piracetam is used as an adjunctive treatment for myo- Indications to extend life in patients with amyotrophic clonus of cortical origin.

lateral sclerosis, initiated by specialists experienced in Riluzole is used to extend life in patients with motor

nervous

the management of motor neurone disease

neurone disease who have amyotrophic lateral sclerosis. Cautions history of abnormal hepatic function (con- sult product literature for details)

NICE guidance Blood disorders Patients or their carers should be told how

syst

Riluzole for motor neurone disease (January to recognise signs of neutropenia and advised to seek

immediate medical attention if symptoms such as fever occur; white blood cell counts should be determined in

em

2001) Riluzole is recommended for treating the amyo-

febrile illness; neutropenia requires discontinuation of rilu- trophic lateral sclerosis (ALS) form of motor neurone

zole Driving

disease (MND). Treatment should be initiated by a Dizziness or vertigo may affect performance of skilled tasks (e.g. driving) specialist in MND but it can then be supervised

Contra-indications hepatic impairment; renal impair- under a shared-care arrangement involving the gen-

ment (Appendix 3); pregnancy (Appendix 4); breast- eral practitioner.

feeding (Appendix 5) Side-effects nausea, vomiting, diarrhoea, abdominal pain; tachycardia; asthenia, headache, dizziness,

drowsiness, oral paraesthesia; less commonly pan- Indications

HALOPERIDOL

creatitis and anaemia; rarely neutropenia; very rarely motor tics, adjunctive treatment in chor-

hepatitis

4.2.1 Dose Cautions section 4.2.1

eas and Tourette syndrome; other indications, section

50 mg twice daily; CHILD not recommended Contra-indications section 4.2.1

Rilutek c (Aventis Pharma) A Side-effects section 4.2.1

Tablets , f/c, riluzole 50 mg. Net price 56-tab pack = Dose

£242.39. Counselling, blood disorders, driving . By mouth , 0.5–1.5 mg 3 times daily adjusted

according to the response; 10 mg daily or more may occasionally be necessary in Tourette syndrome;

TETRABENAZINE

CHILD 5–12 years, Tourette syndrome, 12.5– Indications see under Dose

25 microgram/kg twice daily, adjusted according to Cautions pregnancy (Appendix 4); avoid in breast- response up to max. 10 mg daily

feeding; interactions: Appendix 1 (tetrabenazine) Driving May affect performance of skilled tasks (e.g. driving)

Preparations Side-effects drowsiness, gastro-intestinal distur- Section 4.2.1

bances, depression, extrapyramidal dysfunction,

4.9.3 Drugs used in essential tremor, chorea, tics, and related disorders BNF 57 hypotension; rarely parkinsonism; neuroleptic malig-

conjunctivitis; rarely eyelid bruising and swelling (minimised nant syndrome reported

by applying gentle pressure at injection site immediately Dose

after injection); very rarely angle-closure glaucoma, corneal ulceration

. Movement disorders due to Huntington’s chorea, Specific side-effects in paediatric cerebral palsy Drow- hemiballismus, senile chorea, and related neurological

siness, paraesthesia, urinary incontinence, myalgia conditions, initially 12.5 mg twice daily (elderly

Specific side-effects for temporary improvement of

12.5 mg daily) gradually increased to 12.5–25 mg 3 moderate to severe wrinkles between the eyebrows times daily; max. 200 mg daily

Headache; ptosis; less commonly nausea, dry mouth, facial oedema, dizziness, asthenia, anxiety, paraesthesia, visual

. Moderate to severe tardive dyskinesia, initially disturbances, blepharitis, photosensitivity reactions, and dry

12.5 mg daily, gradually increased according to

skin

response Specific side-effects in spasmodic torticollis Dysphagia and pooling of saliva (occurs most frequently after injection Xenazine c 25 (Cambridge) A into sternomastoid muscle), nausea, dry mouth, rhinitis,

Tablets , yellow, scored, tetrabenazine 25 mg. Net drowsiness, headache, dizziness, hypertonia, stiffness; less price 112-tab pack = £100.00. Label: 2

commonly dyspnoea, voice alteration, diplopia, and ptosis Specific side-effects in axillary hyperhidrosis Non-axil- lary sweating, hot flushes; less commonly myalgia and joint pain

Torsion dystonias and other Specific side-effects in focal upper-limb spasticity

associated with stroke Dysphagia; hypertonia; less com-

involuntary movements

monly arthralgia and bursitis

tem

Botulinum toxin type A should be used under specialist Dose sys supervision. Botox c and Dysport c are licensed for the . Consult product literature (important: specific to

treatment of focal spasticity (including arm symptoms each individual preparation and not interchange- in conjunction with physiotherapy, dynamic equinus

able)

foot deformity caused by spasticity in ambulant paed- Botox c (Allergan) A l nervous iatric cerebral palsy patients over 2 years of age, hand Injection , powder for reconstitution, botulinum toxin

and wrist disability associated with stroke), blepharos- type A complex, net price 50-unit vial = £72.30, 100-

entra pasm, hemifacial spasm, and spasmodic torticollis.

unit vial = £128.93

C Botox c is also licensed for severe hyperhidrosis of the Dysport c axillae.

(Ipsen) A