What is the first-line treatment for akathisia induced by Aripiprazole (Abilify)?

From the Guidelines

The first-line treatment for akathisia caused by aripiprazole is dose reduction or discontinuation of aripiprazole when clinically feasible, as recommended by the American Psychiatric Association 1. When this is not possible, adding a beta-blocker such as propranolol at 10-30 mg three times daily is a viable alternative, as it can provide quick relief within 30-60 minutes and can be used on an as-needed basis.

Key Considerations

• The American Psychiatric Association suggests (2C) that patients who have akathisia associated with antipsychotic therapy may benefit from lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent 1.
• Alternative options include benzodiazepines like lorazepam 1-2 mg or clonazepam 0.5-1 mg, which can provide rapid relief but should be used cautiously due to dependence risk.
• Anticholinergic medications such as benztropine 1-2 mg twice daily may also help, though they're generally less effective for akathisia than for other extrapyramidal symptoms.

Non-Pharmacological Approaches

• Reassurance that the symptoms are medication-related and not worsening psychiatric illness
• Encouraging physical activity to release tension
• Ensuring adequate hydration and rest It is essential to note that akathisia occurs because aripiprazole's partial dopamine agonism can still block dopamine receptors in the nigrostriatal pathway, creating an imbalance between dopaminergic and cholinergic systems that manifests as motor restlessness.

Treatment Goals

• Reduce morbidity and mortality associated with akathisia
• Improve quality of life for patients experiencing akathisia
• Minimize the risk of dependence on benzodiazepines and other medications By prioritizing dose reduction or discontinuation of aripiprazole and considering alternative pharmacological and non-pharmacological approaches, healthcare providers can effectively manage akathisia and improve patient outcomes, as outlined in the American Psychiatric Association's practice guideline for the treatment of patients with schizophrenia 1.

From the Research

First Line Treatment for Akathisia from Aripiprazole

• The first line treatment for akathisia, including that induced by aripiprazole, typically involves discontinuing the offending agent or reducing its dose if possible 2, 3.
• If discontinuation or dose reduction is not feasible, switching to a different antipsychotic with a lower risk of akathisia may be considered 4, 3.
• Beta-blockers, such as propranolol, are commonly used as a first-line treatment for akathisia, although their efficacy can be modest and they may have side effects 4, 5.
• Low-dose mirtazapine, an antidepressant with serotonin 5-HT2a receptor antagonism, has also shown promise in treating akathisia, particularly in cases where propranolol is not effective or tolerated 5.
• Other treatment options for akathisia include anticholinergics, benzodiazepines, and vitamin B6, although the evidence for their efficacy varies and they should be used with caution 2, 3.

Treatment Considerations

• Treatment of akathisia should be personalized, taking into account the individual's specific symptoms, medical history, and response to previous treatments 3.
• A systematic assessment of akathisia using a validated scale is recommended before starting antipsychotics and during dosage titration 3.
• The choice of adjuvant medications should favor established treatments, with careful consideration of contraindications and side effects 3.
• Rotation between different pharmacological management strategies may be optimal in resistant cases of akathisia 4.