How do I manage akathisia caused by antipsychotic (anti-psychotic) medications?

Management of Antipsychotic-Induced Akathisia

For patients with akathisia associated with antipsychotic therapy, the recommended management options include lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent. 1

First-Line Interventions

Dose Reduction or Medication Switch

1. Dose reduction: Lower the dose of the current antipsychotic if clinically feasible
2. Medication switch: Consider switching to an antipsychotic with lower akathisia risk profile:
   • Lowest risk: Iloperidone (3.9%), asenapine (6.8%)
   • Moderate risk: Brexpiprazole (10.0%), quetiapine
   • Higher risk: Lurasidone (12.7%), cariprazine (17.2%) 2

Pharmacological Interventions

1. Beta-blockers: Propranolol is the most consistently effective treatment for acute akathisia 3

   • Starting dose: 10-20 mg three times daily
   • Maximum dose: 120 mg/day
   • Contraindications: Asthma, bradycardia, heart block, heart failure

2. Benzodiazepines: Consider especially when subjective distress persists

   • Lorazepam: 1-2 mg/day
   • Clonazepam: 0.5-2 mg/day

Second-Line Interventions

1. Mirtazapine: Demonstrated efficacy in controlled trials 4

   • Dosage: 7.5-15 mg once daily
   • Response rate of 53.8% vs 7.7% for placebo
   • Better tolerated than propranolol
   • Especially useful for patients with contraindications to beta-blockers or those with comorbid depression

2. Anticholinergic medications: Less effective for akathisia than for other extrapyramidal symptoms

   • Benztropine: 1-2 mg daily (maximum 6 mg daily) 5

3. Other agents (if above treatments fail):

   • Amantadine: 100-300 mg/day
   • Clonidine: 0.1-0.3 mg/day
   • Cyproheptadine, trazodone, or mianserin 6

Treatment Algorithm

1. Initial assessment:

   • Confirm diagnosis of akathisia (subjective inner restlessness and objective motor restlessness)
   • Rule out other causes of restlessness (anxiety, agitation, tardive dyskinesia)

2. First step: Reduce antipsychotic dose if clinically feasible

3. Second step: If dose reduction is not possible or ineffective:

   • Add propranolol 10-20 mg three times daily (if no contraindications)
   • OR add mirtazapine 7.5-15 mg at bedtime (especially if propranolol is contraindicated)

4. Third step: If inadequate response:

   • Consider switching to an antipsychotic with lower akathisia risk
   • Add a benzodiazepine if not already tried

5. Fourth step: For refractory cases:

   • Try combination therapy
   • Consider amantadine or clonidine

Monitoring and Follow-up

• Assess response using standardized scales (e.g., Barnes Akathisia Rating Scale)
• Monitor for side effects of added medications:
  • Propranolol: Hypotension, bradycardia
  • Benzodiazepines: Sedation, cognitive impairment
  • Mirtazapine: Drowsiness, weight gain

Important Considerations

• Akathisia can significantly impact medication adherence and quality of life
• The severity of akathisia with newer antipsychotics is generally mild to moderate but can lead to treatment discontinuation in some cases (<5%) 2
• Risk factors for extrapyramidal symptoms include elderly and very young patients, males, previous history of tremors, previous antipsychotic use, polypharmacy, and higher antipsychotic doses 5
• Prevention is preferable to treatment - consider using antipsychotics with lower akathisia risk when initiating therapy

By following this structured approach to managing antipsychotic-induced akathisia, clinicians can effectively reduce patient distress and improve medication adherence, ultimately leading to better treatment outcomes.