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Dear Dr. Roach: About five years ago, I came down with essential tremor. I have tried many medicines. Currently, I’m taking propranolol and primidone, but nothing seems to help. The only thing that stops the shaking is a glass of wine. I have inquired about a laser procedure, but I found out that it’s a risky procedure. An MRI was normal. I am 82 and in excellent health. I would like to know if there is anything new to help me.

J.M.

Dear J.M.: A lot of people have essential tremor — 5 percent of people worldwide. It causes a noticeable tremor, usually of the hands and arms, but also may affect the head or other body parts. The severity is variable. Some people will be annoyed by symptoms, while others have real difficulty eating or writing. An expert sometimes is needed to confirm the diagnosis, as it can appear to be similar to Parkinson’s disease or other neurological conditions. However, improvement with alcohol is suggestive of essential tremor. Unfortunately, alcohol is not a good long-term treatment, as people build tolerance.

Propranolol is a beta blocker, and primidone is an anti-epilepsy drug. They are the most common pharmacologic treatments for essential tremor. You probably have tried gabapentin and topiramate, two other anti-epilepsy drugs that work for some people, but may have significant side effects.

My first patient to go through ultrasound treatment for essential tremor did so a few months ago. This uses many focused ultrasound beams to heat an area of the brain called the thalamus, destroying the cells responsible for the tremor. This procedure is effective for most people, but it can have side effects, including weakness, gait disturbance and numbness. It is not clear how long the relief will last. It is an option for people whose symptoms are significantly interfering with their quality of life and who have not gotten good relief from medications. It is not yet covered by most insurances. You can read more about it at bit.ly/2FPFlf9.

Dear Dr. Roach: I’ve been taking Viagra for several years, with positive results for my wife and me. We have a very active sex life. Recently my prescription drug coverage administrator has begun restricting my access to 12 pills every 30 days. I’ve requested an explanation from the company, without success. My prescription is written by my heart doctor, and he is not aware of any reason to restrict my access to Viagra. Is there some danger in taking Viagra (sildenafil) on a regular basis? The literature supplied with the prescription, from Pfizer, does not indicate a limit on use. I’d appreciate your feedback on this, as it will affect my wife’s and my happiness.

J.R.

Dear J.R.: The insurance company isn’t worried about your safety: Sildenafil (Viagra) and similar drugs are safe for daily use in most people, and your cardiologist is certainly the right person to make that determination, not your insurance company. Instead, the drug limits are there to save money for the insurance company. People can make up their own minds about whether that is reasonable or not, but it is a near-universal finding now.

One way many patients get around this (if they are taking 25 mg or 50 mg) is to get the larger-size tablet and cut it in half (a pill cutter can do this well), since the limit is on the number of tablets, not the number of milligrams.

Email questions to ToYourGoodHealth@med.cornell.edu.

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