What are the treatment options for akathisia?

From the Guidelines

Akathisia treatment primarily involves addressing the underlying cause, often by adjusting or discontinuing the medication causing this distressing movement disorder, with first-line pharmacological treatment including beta-blockers, such as propranolol, or alternatives like anticholinergic medications or benzodiazepines, as suggested by the American Psychiatric Association 1. The treatment of akathisia should prioritize reducing morbidity, mortality, and improving quality of life, with a focus on promptly addressing the underlying cause of this condition.

• Key treatment options include:
  • Beta-blockers, such as propranolol, at doses of 30-120 mg/day, which have been shown to be effective in treating akathisia 1
  • Anticholinergic medications, like benztropine (1-4 mg/day) or diphenhydramine (25-50 mg every 6-8 hours), as alternatives to beta-blockers
  • Benzodiazepines, such as lorazepam (1-2 mg/day) or clonazepam (0.5-2 mg/day), which may provide short-term relief but carry addiction risks
• For persistent cases, considering switching to a lower-risk antipsychotic (if applicable), adding vitamin B6 (600-1200 mg/day), or trying mirtazapine (15 mg at bedtime) may help, as suggested by the American Psychiatric Association 1
• Non-pharmacological approaches, including reducing caffeine intake and practicing relaxation techniques, can also be beneficial in managing akathisia The American Academy of Child and Adolescent Psychiatry also suggests that lowering the antipsychotic dose, using β-blockers, and benzodiazepines can be helpful in treating akathisia 2. However, the most recent and highest quality study, published in 2020 by the American Psychiatric Association 1, recommends beta-blockers, such as propranolol, as the first-line treatment for akathisia, highlighting the importance of evidence-based treatment in reducing morbidity, mortality, and improving quality of life.

From the Research

Treatment Options for Akathisia

The treatment options for akathisia can be categorized into several classes, including:

• Reducing the dose of antipsychotic medication or switching to a second-generation antipsychotic that is less prone to inducing akathisia 3
• Using rescue agents such as: + Beta-blockers (e.g. propranolol) 3, 4, 5, 6 + Anticholinergics (e.g. biperiden, trihexyphenidyl) 3, 4, 7 + Benzodiazepines 4, 7 + Serotonin 5-HT2a receptor antagonists (e.g. mianserin, cyproheptadine, mirtazapine) 3, 5, 7 + Other agents such as clonidine, amantadine, gabapentin, pregabalin, and vitamin B6 3, 4, 6

Pharmacological Agents

Several pharmacological agents have been examined as treatment options for antipsychotic-induced akathisia, including:

• Mirtazapine, which has demonstrated compelling evidence for therapeutic efficacy 5
• Propranolol, which is currently considered a first-line treatment for antipsychotic-induced akathisia, but has modest evidence for its anti-akathisia effect and may have limitations due to side effects and contraindications 4, 5, 6
• Vitamin B6, which may be beneficial for ameliorating antipsychotic-induced akathisia, with similar efficacy to propranolol 6

Management Approaches

The management of akathisia involves a variety of approaches, including:

• Prevention through standardized titration and the use of novel antipsychotics 4
• Treatment with pharmacological agents, as outlined above
• Reduction or withdrawal of antipsychotic medication, although this may not always be possible 7