From the Guidelines
For treating extrapyramidal symptoms, I recommend starting with an anticholinergic medication such as benztropine (Cogentin) 1-2 mg orally twice daily or trihexyphenidyl 2-5 mg orally three times daily, as these medications have been shown to be effective in managing extrapyramidal side effects associated with antipsychotic use 1. The treatment of extrapyramidal symptoms (EPS) is crucial in managing the side effects of antipsychotic medications.
- Anticholinergic medications, such as benztropine and trihexyphenidyl, work by blocking cholinergic receptors in the basal ganglia, helping to restore the dopamine-acetylcholine balance that is disrupted by antipsychotic medications.
- Alternatively, diphenhydramine (Benadryl) 25-50 mg orally three times daily can be effective in treating EPS, as it also has anticholinergic properties.
- If symptoms persist, dose reduction of the antipsychotic medication should be considered, or switching to an antipsychotic with lower EPS risk like quetiapine or aripiprazole may be necessary, as suggested by the practice parameter on the use of psychotropic medication in children and adolescents 1.
- Treatment should continue until EPS resolves, usually within 1-2 weeks, followed by gradual tapering of the anticholinergic medication.
- It is essential to monitor for anticholinergic side effects, including dry mouth, blurred vision, constipation, and urinary retention.
- For severe or persistent akathisia specifically, beta-blockers like propranolol 10-30 mg three times daily may be more effective than anticholinergics, as they can help alleviate the symptoms of akathisia.
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. 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 for extrapyramidal symptoms is benztropine with a recommended 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.
- In cases of acute dystonic reactions, an injection of 1 to 2 mL can provide quick relief, followed by 1 to 2 mg tablets twice a day to prevent recurrence.
From the Research
Treatment Options for Extrapyramidal Symptoms
The treatment for extrapyramidal symptoms (EPS) typically involves the use of antiparkinsonian medications. Some key points to consider include:
- Anticholinergic agents, such as benztropine mesylate, are commonly used to treat EPS, but they can also produce side effects like gastrointestinal disturbances, visual difficulties, and tardive dyskinesia 3.
- Amantadine hydrochloride is an alternative treatment option that has been shown to be comparable in effect to benztropine mesylate, but with fewer side effects 3, 4.
- Amantadine may be particularly useful in patients who cannot tolerate antiparkinsonian medications with anticholinergic properties 3, 4.
Antiparkinsonian Medications
Antiparkinsonian medications are the mainstay of treatment for neuroleptic-induced extrapyramidal symptoms. Key points to consider include:
- These medications can help alleviate symptoms, but they may not completely eliminate them 4, 5.
- The choice of antiparkinsonian medication depends on various factors, including the patient's medical history, the severity of symptoms, and the potential for side effects 5.
Special Considerations
In some cases, extrapyramidal symptoms can occur as a result of treatment with antidepressants, rather than neuroleptics. Key points to consider include:
- Selective serotonin reuptake inhibitors (SSRIs) and other antidepressants can cause EPS, particularly in older adults 6.
- The onset of EPS can occur at any dosage, and clinicians should be aware of this potential side effect when prescribing antidepressants 6.
- The adjunct of certain medications, such as nortriptyline, to existing treatment regimens can also increase the risk of EPS 7.