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Difficulty: EasyPharmacologic Interventions

During a routine health maintenance visit, a 4242-year-old woman reports difficulty performing fine motor tasks at work due to a bilateral hand tremor. The tremor is most prominent during voluntary movements. She is diagnosed with essential tremor and requests medical therapy. Her medical records indicate a longstanding history of moderate persistent asthma, currently managed with a daily budesonide inhaler and an as-needed albuterol inhaler. As the physician considers initiating pharmacotherapy for her tremor, which of the following agents should be avoided?

  1. PropranololAnswer
  2. B
    Primidone
  3. C
    Gabapentin
  4. D
    Topiramate
  5. E
    Clonazepam

Answer

Propranolol
The correct answer is propranolol. Propranolol is a non-selective beta-adrenergic antagonist frequently used as a first-line treatment for essential tremor. However, because it antagonizes β2\beta_2 receptors in the bronchial smooth muscle, it can precipitate severe bronchospasm. Therefore, it is absolutely contraindicated in patients with reactive airway diseases such as asthma. Patients with essential tremor and concurrent asthma should instead be offered alternative first-line agents, such as primidone.

Step-by-Step Solution

1
Identify the patient's primary diagnosis and the secondary comorbidity.
The patient requires treatment for essential tremor and has a comorbid diagnosis of moderate persistent asthma.
Choosing a pharmacologic intervention requires reviewing the patient's medical history for potential contraindications.
2
Evaluate standard therapies for essential tremor against the patient's asthma.
Propranolol, a non-selective beta-blocker, is a first-line treatment for essential tremor but can trigger severe bronchospasm in asthmatic patients.
Non-selective beta-blockers antagonize β2\beta_2 receptors in the lungs, reversing or preventing the bronchodilatory effects of endogenous catecholamines and medications like albuterol.
3
Determine the contraindicated medication.
Propranolol must be avoided; the patient should be offered an alternative such as primidone.
Patient safety dictates avoiding medications that directly exacerbate underlying chronic conditions when safe alternatives exist.

Key Concept

Absolute contraindications to non-selective beta-blockers in patients with reactive airway disease.
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Topics

Pharmacologic Interventions

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