What is the treatment for akathisia?

Treatment of Akathisia

The first-line treatment for akathisia includes lowering the dosage of the causative antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine, or adding a beta-adrenergic blocking agent such as propranolol. 1

Understanding Akathisia

Akathisia is a distressing neuropsychiatric syndrome characterized by:

• Subjective feelings of inner restlessness and urge to move
• Objective components including rocking while standing/sitting, lifting feet as if marching, and crossing/uncrossing legs
• Significant distress that can impact treatment adherence and quality of life

Treatment Algorithm

Step 1: Identify and Address the Cause

• Determine if akathisia is related to antipsychotic medication
• Assess severity using a standardized scale (e.g., Barnes Akathisia Rating Scale)

Step 2: First-Line Interventions

1. Antipsychotic Medication Adjustment:

   • Lower the dosage of the antipsychotic medication if clinically feasible 1
   • Consider switching to an antipsychotic with lower risk of akathisia:
     • Switch to quetiapine or olanzapine which have lower akathisia risk 1
     • Consider atypical antipsychotics which generally have lower risk of extrapyramidal symptoms 2

2. Add Pharmacological Treatment:

   • Beta-blockers: Propranolol 10-30 mg two to three times daily is the most consistently effective treatment 1, 3
   • Benzodiazepines: Can be added if beta-blockers fail or as concurrent therapy 1, 4

Step 3: Second-Line Interventions (if first-line fails)

• 5-HT2A antagonists: Mirtazapine 7.5-15 mg once daily has shown compelling evidence for efficacy 5
• Anticholinergic medications: May provide some relief, particularly if there are other extrapyramidal symptoms 1
• Amantadine or clonidine: Consider when beta-blockers and benzodiazepines fail 3

Special Considerations

Acute vs. Tardive Akathisia

• Acute akathisia typically occurs early in treatment or after dose increases
• Tardive akathisia can persist for years after discontinuation of the causative agent and is more resistant to treatment 6
• For tardive akathisia, catecholamine-depleting drugs like reserpine and tetrabenazine may be more effective 6

Risk Factors for Developing Akathisia

• Higher risk populations include elderly patients, very young patients, males, patients with previous history of tremors, and those on high doses of antipsychotics 2
• Prevalence rates vary widely between 5-36.8% of patients on antipsychotics 3

Monitoring

• Regular assessment of abnormal movements using standardized scales like the Abnormal Involuntary Movement Scale (AIMS) is crucial 2
• Monitor for other extrapyramidal symptoms that may co-occur with akathisia

Common Pitfalls and Caveats

1. Misdiagnosis: Akathisia is often misdiagnosed as anxiety, agitation, or worsening psychosis 7

2. Medication Interactions: Be aware of potential interactions when adding anti-akathisia medications to existing regimens

3. Beta-Blocker Contraindications: Propranolol should be used cautiously in patients with asthma, diabetes, or cardiovascular disease 5

4. Suicide Risk: Untreated akathisia is associated with increased suicidal thoughts and distress 7

5. Long-term Management: While acute akathisia may resolve with intervention, tardive akathisia can persist for years and may require ongoing management 6

By following this structured approach to the treatment of akathisia, clinicians can effectively manage this distressing condition and improve patient outcomes, adherence to treatment, and quality of life.