Department of Neurology, Klinik Ottakring, Vienna, Austria.
Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Klinik Donaustadt, Vienna, Austria.
J Parkinsons Dis. 2023;13(2):127-144. doi: 10.3233/JPD-225060.
The pathophysiology of Parkinson's disease (PD) tremor remains incompletely understood and there is a lack of clinical trials specifically addressing its pharmacological treatment. Levodopa is the most efficacious drug for most patients and should be used as primary approach to control troublesome tremor. While the efficacy of oral dopamine agonists on PD tremor has been demonstrated in controlled trials, there is no evidence of greater antitremor efficacy compared to levodopa. The magnitude of the antitremor effect of anticholinergics is generally lower than that of levodopa. Due to their adverse effects, anticholinergics have a limited role in selected young and cognitively intact patients. Propranolol may improve resting and action tremor and may be considered as an adjunct in patients with insufficient tremor response to levodopa and this also applies to clozapine, despite its unfavorable adverse effect profile. Treating motor fluctuations with MAO-B and COMT inhibitors, dopamine agonists, amantadine, or on-demand treatments such as subcutaneous or sublingual apomorphine and inhaled levodopa as well as with continuous infusions of levodopa or apomorphine will improve off period tremor episodes. For patients with drug-refractory PD tremor despite levodopa optimization deep brain stimulation and focused ultrasound are first-line considerations. Surgery can also be highly effective for the treatment medication-refractory tremor in selected patients without motor fluctuations. The present review highlights the clinical essentials of parkinsonian tremor, critically examines available trial data on the effects of medication and surgical approaches and provides guidance for the choice of treatments to control PD tremor in clinical practice.
帕金森病（PD）震颤的病理生理学仍不完全清楚，并且缺乏专门针对其药物治疗的临床试验。左旋多巴是大多数患者最有效的药物，应作为控制烦人的震颤的主要方法。虽然在对照试验中已经证明了口服多巴胺激动剂对 PD 震颤的疗效，但与左旋多巴相比，没有证据表明其具有更大的抗震颤作用。抗胆碱能药物的抗震颤作用幅度通常低于左旋多巴。由于其不良反应，抗胆碱能药物在某些年轻且认知功能正常的患者中作用有限。普萘洛尔可能改善静止性和动作性震颤，可以考虑作为对左旋多巴震颤反应不足的患者的辅助治疗，这也适用于氯氮平，尽管其不良的不良反应谱。用 MAO-B 和 COMT 抑制剂、多巴胺激动剂、金刚烷胺、按需治疗（如皮下或舌下阿扑吗啡和吸入左旋多巴）以及左旋多巴或阿扑吗啡的持续输注治疗运动波动，将改善停药期震颤发作。对于尽管进行了左旋多巴优化但仍有药物难治性 PD 震颤的患者，深部脑刺激和聚焦超声是首选考虑因素。对于没有运动波动的选定患者，手术也可以非常有效地治疗药物难治性震颤。本综述强调了帕金森震颤的临床要点，批判性地审查了关于药物和手术方法效果的现有试验数据，并为控制 PD 震颤提供了在临床实践中选择治疗方法的指导。
