From the Guidelines
The first-line medication for akathisia is a beta-adrenergic blocking agent, such as propranolol, as suggested by the American Psychiatric Association 1. When managing akathisia, it is essential to consider the potential benefits and risks of treatment, prioritizing the reduction of morbidity, mortality, and improvement of quality of life.
Key Considerations
- The American Psychiatric Association suggests (2C) that patients who have akathisia associated with antipsychotic therapy be treated with options including lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent 1.
- Beta-blockers, such as propranolol, are often the preferred treatment due to their efficacy in reducing the symptoms of akathisia.
- The dosage of propranolol can be adjusted based on the patient's response, typically starting at 10-20 mg two to three times daily, with doses that can be increased up to 120 mg daily if needed.
Alternative Options
- If beta-blockers are contraindicated, alternatives such as benzodiazepines (e.g., lorazepam) or anticholinergic medications (e.g., benztropine) may be considered, although these should be used with caution due to their potential side effects.
- It is crucial to weigh the benefits and risks of each treatment option, considering the individual patient's medical history, current medications, and potential interactions.
Treatment Approach
- Treatment should begin as soon as akathisia is recognized and continue until the symptoms resolve or the causative agent (often an antipsychotic medication) can be reduced or discontinued.
- A comprehensive treatment plan should include efforts to reduce the dose of the causative agent when possible, alongside the management of akathisia symptoms.
From the Research
First-Line Medication for Akathisia
The first-line medication for akathisia is propranolol, a non-selective beta-adrenergic receptor antagonist, as indicated by several studies 2, 3, 4, 5.
Key Points
- Propranolol has been shown to be consistently effective in treating acute akathisia 2, 5.
- The use of propranolol is supported by multiple studies, including an open trial that demonstrated substantial improvement in 14 patients with neuroleptic-induced akathisia 5.
- Other beta-blockers, such as metoprolol and ICI 118,551, have also been shown to be effective in ameliorating neuroleptic-induced akathisia 6.
- Mirtazapine, an agent with marked postsynaptic serotonin 5-HT2a receptor antagonism, has also demonstrated compelling evidence for therapeutic efficacy in treating akathisia 3, 4.
Treatment Options
- Propranolol is considered a first-line treatment for antipsychotic-induced akathisia 3, 4, 5.
- Mirtazapine is also a viable option for treating akathisia, particularly in cases where propranolol is not effective or tolerated 3, 4.
- Other treatment options, such as benzodiazepines, anticholinergic agents, and clonidine, may be considered in certain cases, but the evidence for their effectiveness is less robust 2, 4.