What is the treatment for chronic Extrapyramidal Symptoms (EPS)?

Treatment for Chronic Extrapyramidal Symptoms (EPS)

The primary treatment for chronic extrapyramidal symptoms involves switching to an atypical antipsychotic with lower EPS risk, dose reduction of the current antipsychotic, and if these strategies fail, adding anticholinergic medications or amantadine for symptomatic relief. 1

First-Line Approach: Medication Adjustment

1. Antipsychotic Modification Strategies:

   • Dose reduction of the current antipsychotic if clinically feasible 1
   • Switch to atypical antipsychotics with lower EPS risk:
     • Olanzapine (initial dose 2.5 mg/day at bedtime; maximum 10 mg/day)
     • Quetiapine (initial dose 12.5 mg twice daily; maximum 200 mg twice daily)
     • Risperidone (1.25-3.5 mg/day) 1

2. Specific EPS Treatments Based on Symptom Type:

   • For Parkinsonism symptoms (bradykinesia, tremors, rigidity):

     • Anticholinergic medications (e.g., benztropine)
     • Amantadine (alternative with fewer anticholinergic effects) 2, 1

   • For Akathisia (restlessness, inability to sit still):

     • Beta-blockers (propranolol, metoprolol) are most effective
     • Benzodiazepines may provide relief
     • Anticholinergics are less consistently effective 2, 3

   • For Tardive Dyskinesia:

     • Clozapine has shown antidyskinetic effectiveness
     • GABAergic benzodiazepines (clonazepam)
     • Antioxidants (alpha-tocopherol)
     • Calcium channel blockers (nifedipine) 4

   • For Tardive Dystonia:

     • Higher doses of anticholinergic medication (unlike TD)
     • Local injection of botulinum A toxin for focal dystonia 4

Pharmacological Management with Anticholinergics

When anticholinergic medications are necessary:

• Benztropine dosing: Start with low dose (0.5-1 mg) and increase gradually at 5-6 day intervals
• Typical dosage range: 1-2 mg daily, with maximum of 6 mg daily
• Administration options: Single bedtime dose or divided doses (2-4 times daily) based on patient response 5
• Important considerations:
  • Older and thin patients generally cannot tolerate large doses
  • Long duration of action makes benztropine suitable for bedtime dosing 5
  • When starting benztropine, do not terminate other antiparkinsonian agents abruptly 5

Monitoring and Follow-Up

• Allow 2-4 weeks between medication changes to properly assess response 1
• Regular monitoring for withdrawal symptoms when reducing antipsychotic doses 1
• Monitor metabolic parameters, cardiac function, and EPS symptoms regularly 1
• Reassess the continued need for anticholinergic medications periodically 1

Common Pitfalls to Avoid

1. Misdiagnosis: Akathisia is frequently misinterpreted as psychotic agitation or anxiety, leading to inappropriate treatment 2, 1

2. Prolonged anticholinergic use: Should be avoided when not necessary as it can lead to increased side effects and decreased efficacy 1

3. Antipsychotic polypharmacy: Associated with increased side effect burden, higher risk of drug-drug interactions, and increased risk of EPS and tardive dyskinesia 1

4. Abrupt discontinuation: When reducing antipsychotics or anticholinergics, gradual tapering is essential to avoid withdrawal symptoms 1, 5

5. Inadequate documentation: Failure to reassess the continued need for medications can lead to suboptimal care 1

The evidence clearly shows that atypical antipsychotics have significantly lower risk of EPS compared to typical antipsychotics (12% vs 46%) 6, making them the preferred choice for patients with chronic EPS.