From the Guidelines
The treatment of extrapyramidal symptoms (EPS) primarily involves discontinuing the causative agent when possible and administering anticholinergic medications. For acute dystonic reactions, benztropine 1-2 mg IV/IM or diphenhydramine 25-50 mg IV/IM provides rapid relief, followed by oral therapy for 2-7 days 1. For ongoing management of drug-induced parkinsonism, oral anticholinergics like benztropine 1-2 mg twice daily, trihexyphenidyl 2-5 mg three times daily, or amantadine 100 mg twice daily are effective. Akathisia often responds to beta-blockers such as propranolol 10-30 mg three times daily or benzodiazepines like lorazepam 0.5-2 mg twice daily. Some key points to consider in the treatment of EPS include:
- The use of atypical antipsychotic agents, which have a lower risk of extrapyramidal symptoms compared to traditional antipsychotic agents 1.
- The potential for serious side effects, such as weight gain, neutropenia, and seizures, associated with the use of atypical antipsychotic agents 1.
- The importance of regular monitoring for symptom improvement and medication side effects, particularly in elderly patients 1.
- The use of VMAT2 inhibitors, such as valbenazine, deutetrabenazine, or tetrabenazine, for the treatment of tardive dyskinesia 1. It is essential to weigh the benefits and risks of each treatment option and to individualize treatment based on the patient's specific needs and circumstances.
From the FDA Drug Label
In treating extrapyramidal disorders due to neuroleptic drugs (e.g., phenothiazines), the recommended dosage is 1 to 4 mg once or twice a day orally, or parenterally. Dosage must be individualized according to the need of the patient. Some patients require more than recommended; others do not need as much. In acute dystonic reactions, 1 to 2 mL of the injection usually relieves the condition quickly After that, the tablets, 1 to 2 mg twice a day, usually prevents recurrence.
The treatment of extra pyramidal symptoms with benztropine is done with a dosage of 1 to 4 mg once or twice a day orally, or parenterally 2.
- The dosage must be individualized according to the need of the patient.
- Acute dystonic reactions can be relieved with 1 to 2 mL of the injection, and then 1 to 2 mg tablets twice a day can prevent recurrence.
From the Research
Treatment Options for Extra Pyramidal Symptoms
- Anticholinergic medications or benzodiazepines can be used to treat acute dystonias 3
- Pseudoparkinsonism can be managed by lowering the antipsychotic dosage or by adding an anticholinergic agent or a mantadine; switching to a low-potency agent or an atypical antipsychotic may also help 3
- Akathisia can be treated with anticholinergic, beta-blocker, or benzodiazepine, with lipophilic beta-blockers such as propranolol and metoprolol appearing to be the most effective treatments 3
- Atypical antipsychotics may have less potential to induce extra pyramidal symptoms (EPS) compared to conventional antipsychotics 4, 5
Prevention of Extra Pyramidal Symptoms
- Using the lowest effective dosage of antipsychotic can help prevent EPS 3
- Treating the reactions with medications can also help prevent EPS 3
- Changing the antipsychotic to one with less potential for inducing EPS can also be an option 3
- Anticholinergic agents can be given to prevent acute dystonias, especially in high-risk patients, but long-term prophylaxis is controversial 3
Epidemiology of Extra Pyramidal Symptoms
- The incidence of dystonia is 2-3% among patients treated with antipsychotics, and 50% among those cured with conventional antipsychotics 4
- The incidence and prevalence of akathisia ranges from 5 to 50% among treated patients 4
- The pooled prevalence of antipsychotic-induced EPS among patients taking antipsychotic medications was 37% (95% CI: 18-55%) and 31% (95% CI: 19-44%) after sensitivity analysis 6
- The prevalence of antipsychotic-induced parkinsonism, akathisia, and tardive dyskinesia was 20% (95% CI: 11-28%), 11% (95% CI: 6-17%), and 7% (95% CI: 4-9%), respectively 6