Decadron and Hand Tremor - 1257421

double trouble
Posts:573

Janine, maybe Dr. Walko would be available to answer this.

I have been taking 2 mg. daily of dexamethasone, which has worked to decrease pain, increase energy, and has helped my breathing. However, I am experiencing hand tremors that make everyday tasks very difficult. I had very mild tremor already, but it was barely noticeable. Now it is difficult to feed myself, write, etc.

At the same time they started the dexamethasone, they reduced my dose of propranolol to 10mg. bid. I understand this may have exacerbated the tremor since propranolol is used to treat essential tremor.

Is there a solution other than just discontinuing the steroid? Perhaps a different steroid or alternative that will reap the benefits without the tremor?

Thanks,
Debra

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Reply # - June 21, 2013, 10:29 PM

Dr West
Posts: 4735

I don't have enough knowledge of the different steroid preparations to say whether one is a better choice here than another. The general teaching is that they are more similar than different. However, what I'd wonder about is whether, with a very wide range of medications to treat pain, even including some local treatments like lidocaine patches for the right situation), would a different pain medication be feasible as an alternative to dexamethasone (also known as Decadron)?

Also, Dr. Walko may have a more definitive answer, but I'm not aware of a clear reason that someone would need to cut their propranolol dose when starting decadron, especially at what is still a pretty low dose. I've never cut someone's beta blocker dose automatically when starting dexamethasone, and I would definitely wonder if that's at all necessary when we're talking about just 2 mg per day.

Good luck.

-Dr. West

Reply # - June 22, 2013, 02:45 AM

double trouble
Posts: 573

Thank you for your reply Dr. West. The propranolol, which was prescribed as prophylaxis for portal hypertension, was cut because my blood pressure was so low while I was in hospital. I don't think the cut was associated with the addition of decadron. The decisions were made by two different doctors who perhaps were not on the same page. I think the drop in the dosage has exacerbated the tremor though.

The decadron was added by the palliative team to address general body aches and pains that come and go, and move around the body, bone and joint, wear and tear, aggravated by the weather kind of pain that really isn't well controlled by my regular regimen of tramadol and lyrica. The addition of decadron has been delightfully effective. I've been as close to pain free as a patient has a right to hope for since I started taking it. There's just the little problem of not being able to get food to my mouth from the plate, that's if I can get it on the fork at all! The tremor comes and goes, and gets worse with stress.

Since starting decadron, I have more energy, mental clarity and focus, and I don't hurt all the time. It is almost worth putting up with the tremors. Still very short of breath on exertion though. And while I worry about being on a steroid for any long period of time, I guess if my prognosis is being interpreted in terms of months, it becomes less of an issue. But I am wondering if a lower dose or different steroid would quiet the tremor or perhaps coming back up on the dose of propranolol and monitoring BP more often.

The asthma inhalers might not be helping either! So many drugs, so many side effects and interactions. It never gets boring!

Debra

Reply # - June 22, 2013, 02:31 PM

catdander
Posts:

Debra, Dr. Walko is traveling without internet for a long weekend. Good for her. I'm sure she'll check in when she gets back to civilization. ;)

Reply # - June 22, 2013, 04:45 PM

JimC
Posts: 2753

Debra,

I'm just wondering if a slight dosage reduction of the decadron (even though it's a low dose to begin with) has been discussed, since that often needs to be done to reach the right mix of efficacy and side effects.

JimC
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Reply # - June 23, 2013, 12:43 PM

carrigallen
Posts: 194

In general, in my experience, low-dose steroids do not cause a noticeable tremor. It seems like the cause may be related to reduction in propranolol dose.
Healthcare providers are quick to become alarmed when they see a low blood pressure. However, patients with portal hypertension often run fairly low blood pressures at baseline. Blood pressure has to be viewed in context. These baseline low blood pressures can be asymptomatic. Often, splanchnic varices prophylaxis (propranolol or nadolol) may be discontinued presumptiously by providers who are not familiar with portal hypertension or those providers who do not understand why the drug is being given.
Bottom line: I suggest discussing with your doctor the option of resuming your previous propranol dose or discussing the option of trying nadolol instead. Be aware, these drugs involve complicated pathways (endocrine, autonomic, etc) so it can require repetitive fine-tuning in medications with your doctor to reach an optimal point. Good luck!

Reply # - June 24, 2013, 06:31 AM

dr walko
Posts: 102

Debra,

Sorry for the delay in response, I was in Richmond this weekend with limited email access. I completely agree with Drs. West and Creelan. Discussing resuming the propranol seems like it may be a good place to start. As most steroid veterans know, dexamethasone can definitely cause a "jittery" feeling but generally not tremors like you are describing.

My only other thought/question would be if you started/stopped any other medications or for some reason started drinking more caffeine beverages or herbals?

Best wishes,
Dr. Walko

Reply # - June 24, 2013, 08:27 AM

double trouble
Posts: 573

Thank you all. Especially Dr. Creelan. I think they did have a bit of a knee jerk reaction to the low blood pressure while I was in hospital. And thank you for your discussion on portal hypertension. I know it's a bit off topic for this website. I do understand the need to titrate the dosage as well. Thank you again.

It is good to know that the steroid is not contributing, as it is providing me with so much pain relief I would really like to continue with it as long as it is safe. Dr. Walco, I hope Richmond was a pleasure trip. There is a definite difference between this tremor and the "jittery" feeling you describe, which I did experience when they gave me albuterol breathing treatments That stuff doesn't agree with me at all! Very little caffeine consumption.

Now I just have to figure out who I need to work with to get the propranolol dosage where it needs to be. It was originally prescribed by the liver transplant team, is refilled by my primary, and was changed by the hospital attending on the floor I was on. Fun stuff. I think the liver team will be my best bet on this one.

Thanks again so much.
Debra

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