From the Guidelines
The recommended treatment for akathisia is to first attempt lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent, as suggested by the American Psychiatric Association 1. When treating akathisia, it is essential to consider the potential causes and consequences of the condition. Akathisia is often associated with the use of antipsychotic medications, which can lead to a dopamine-acetylcholine imbalance in the basal ganglia. Some key considerations for treating akathisia include:
- Lowering the dosage of the antipsychotic medication to minimize side effects while still maintaining therapeutic efficacy
- Switching to another antipsychotic medication with a lower risk of akathisia, such as quetiapine or olanzapine
- Adding a benzodiazepine medication, such as lorazepam or clonazepam, to provide rapid relief for acute symptoms
- Adding a beta-adrenergic blocking agent, such as propranolol, to help alleviate symptoms The American Academy of Child and Adolescent Psychiatry also suggests that antiparkinsonian agents, β-blockers, and benzodiazepines may be helpful in treating akathisia 1. However, the most recent and highest-quality study, published in 2020 by the American Psychiatric Association, suggests that the above-mentioned treatment options are the most effective for managing akathisia 1. Regular physical activity and relaxation techniques can also be beneficial as non-pharmacological approaches. Treatment should be individualized based on symptom severity, with close monitoring for side effects, as akathisia can significantly impact medication adherence and quality of life.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION ... Drug-Induced Extrapyramidal Disorders - 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. Certain drug-induced extrapyramidal disorders that develop slowly may not respond to benztropine mesylate.
The recommended treatment for akathisia, which is a type of extrapyramidal disorder, is 1 to 4 mg of benztropine mesylate once or twice a day orally or parenterally, with dosage individualized according to the need of the patient 2.
- Key points:
- Dosage: 1 to 4 mg once or twice a day
- Administration: orally or parenterally
- Individualization: dosage must be individualized according to the need of the patient
- Important consideration: certain drug-induced extrapyramidal disorders that develop slowly may not respond to benztropine mesylate.
From the Research
Treatment Options for Akathisia
The recommended treatment for akathisia includes:
- Propranolol, a non-selective beta-adrenergic receptor antagonist, which is currently considered a first-line treatment for antipsychotic-induced akathisia (AIA) 3
- Vitamin B6, which has been found to be effective in the treatment of neuroleptic-induced akathisia in several studies 4, 5, 6
- Serotonin 5-HT2a receptor antagonists, such as mianserin, which have been found to be effective in the treatment of acute neuroleptic-induced akathisia 6
- Low-dose mirtazapine, which has demonstrated compelling evidence for therapeutic efficacy in the treatment of AIA 3
Comparison of Treatment Options
Studies have compared the efficacy of different treatment options for akathisia, including:
- Vitamin B6 versus propranolol, which found that vitamin B6 attenuated akathisia similar to propranolol 4
- Vitamin B6 versus mianserin and placebo, which found that both vitamin B6 and mianserin were effective in reducing symptoms of akathisia 6
- Propranolol, which has been found to be effective in reducing symptoms of akathisia in several studies 3, 7
Limitations of Treatment Options
While these treatment options have been found to be effective, they also have limitations, including: