What is the recommended starting dose of propranolol (beta blocker) for akathisia?

From the Guidelines

The recommended starting dose of propranolol for akathisia is 20-30 mg, with the most recent and highest quality evidence suggesting a dose of 20 mg orally, two to three times daily. When initiating treatment, it's essential to start at the lower end of the dosing range and titrate upward based on symptom response and tolerability 1. Propranolol works quickly, often providing relief within 30-60 minutes of administration, making it valuable for acute management of akathisia. The medication works by blocking beta-adrenergic receptors, which helps reduce the peripheral manifestations of akathisia such as restlessness and the urge to move.

Key Considerations

• Before starting propranolol, patients should be screened for contraindications including bradycardia, heart block, asthma, and certain cardiac conditions.
• Blood pressure and heart rate should be monitored, especially during dose adjustments.
• For patients with hepatic impairment, lower doses may be necessary as propranolol is metabolized in the liver.
• If akathisia symptoms persist despite adequate propranolol treatment, alternative or additional interventions should be considered.

Dosing and Administration

• The dose can be gradually increased as needed, with most patients responding to total daily doses between 30-120 mg.
• Propranolol can be administered orally, two to three times daily.
• The medication should be titrated upward based on symptom response and tolerability.

Evidence-Based Recommendations

• The most recent and highest quality evidence suggests a starting dose of 20 mg orally, two to three times daily 1.
• Other studies support the use of propranolol for akathisia, but the recommended starting dose may vary 1.

From the Research

Propranolol Starting Dose for Akathisia

• The recommended starting dose of propranolol for akathisia is typically low, ranging from 10-40 mg/day 2, with some studies suggesting doses as low as 30-80 mg/day 3 can be effective.
• A case report suggests that a dose of 40 mg/day of propranolol can be effective in treating amisulpride withdrawal akathisia 4.
• Another study found that doses of 20-40 mg/day of propranolol were effective in treating neuroleptic-induced akathisia 5.
• It is worth noting that the dose of propranolol required for improvement can vary depending on the individual patient and the specific circumstances of their akathisia, with some patients responding to lower doses and others requiring higher doses 3, 5, 6, 2.

Key Findings

• Propranolol has been shown to be effective in treating neuroleptic-induced akathisia in several studies 3, 5, 6, 2.
• The exact mechanism of action of propranolol in treating akathisia is not fully understood, but it is thought to involve beta-1 adrenoceptor blockade 5, 6.
• Propranolol may be a useful treatment option for patients with akathisia who have not responded to other treatments, such as anticholinergic antiparkinson drugs or phenobarbital 2.

Dosing Considerations

• The dose of propranolol should be individualized based on the patient's response to treatment and the presence of any side effects 3, 5, 6, 2.
• Propranolol can be started at a low dose and gradually increased as needed and as tolerated 2.
• Patients should be monitored closely for signs of improvement or side effects, and the dose of propranolol should be adjusted accordingly 3, 5, 6, 2.