What is the treatment for Extrapyramidal Symptoms (EPS)?

Treatment of Extrapyramidal Symptoms (EPS)

The first-line treatment for extrapyramidal symptoms (EPS) is anticholinergic medication, specifically benztropine 1-2 mg daily, which can be administered orally or parenterally depending on symptom severity and patient ability to take oral medication. 1, 2

Treatment Approach Based on EPS Type

1. Acute Dystonia

• First-line treatment:
  • Anticholinergic medications: Benztropine 1-2 mg IV/IM for rapid relief 1, 2
  • Follow with oral benztropine 1-2 mg twice daily to prevent recurrence 2
• Alternative options:
  • Antihistamines (e.g., diphenhydramine) 3
  • Benzodiazepines if anticholinergics are contraindicated 3

2. Drug-Induced Parkinsonism

• Management options (in order of preference):
  • Reduce dose of the causative antipsychotic if clinically feasible 1, 3
  • Add anticholinergic agent: Benztropine 1-2 mg/day, can be increased gradually to maximum 6 mg/day 1, 2
  • Consider amantadine as an alternative 1, 3
  • Switch to an atypical antipsychotic with lower EPS risk (e.g., quetiapine) 1, 3

3. Akathisia

• Management options (in order of preference):
  • Reduce antipsychotic dose if possible 1, 3
  • Beta-blockers: Propranolol (most effective) 1, 3
  • Benzodiazepines 1, 3
  • Note: Anticholinergics are less effective for akathisia than for other EPS 1, 3

4. Tardive Dyskinesia

• Management approach:
  • Prevention and early detection are crucial 1
  • Consider dose reduction or switching to an atypical antipsychotic 1, 3
  • Regular monitoring using scales like AIMS (Abnormal Involuntary Movement Scale) 1

Dosing Considerations for Benztropine

• Initial dosing: Start with low dose (0.5-1 mg) and increase gradually at 5-6 day intervals 2
• Typical maintenance dose: 1-2 mg daily 1, 2
• Maximum dose: 6 mg daily 2
• Administration timing:
  • Some patients benefit from entire dose at bedtime 2
  • Others require divided doses 2-4 times daily 2
• Special populations:
  • Elderly patients: Use lower doses (e.g., 0.5 mg initially) 1, 2
  • Thin patients: Lower doses typically required 2

Risk Factors for EPS

Identifying patients at higher risk for EPS is important for prevention:

• Age extremes (elderly and very young) 1
• Male gender 1
• Previous history of tremors 1
• Previous use of antipsychotics 1
• Polypharmacy 1
• Substance abuse 1
• Higher doses of antipsychotics 1
• Smoking 1

Prevention Strategies

• Use lowest effective dose of antipsychotic medication 3, 4
• Consider prophylactic anticholinergics in high-risk patients 3
• When possible, use atypical antipsychotics which have lower EPS risk (e.g., quetiapine) 1, 5
• Avoid combining antipsychotics with cholinesterase inhibitors when possible, as this combination increases EPS risk 6

Important Cautions

• Long-term prophylactic use of anticholinergics remains controversial 3
• Anticholinergic medications should be avoided in patients with dementia with Lewy bodies due to risk of cognitive worsening 1
• Monitor for anticholinergic side effects (dry mouth, constipation, urinary retention, blurred vision)
• Regular reassessment of the need for continued anticholinergic therapy is recommended

EPS significantly impacts treatment outcomes, including medication adherence, quality of life, and symptom control 4. Prompt recognition and appropriate management are essential to minimize these impacts and improve overall treatment outcomes.