What is the recommended treatment for akathisia?

Treatment of Akathisia

Propranolol is the first-line treatment for antipsychotic-induced akathisia, with doses of 30-80 mg/day typically providing substantial improvement within 24 hours. 1

Understanding Akathisia

Akathisia is a distressing movement disorder characterized by:

• Subjective feelings of inner restlessness and urge to move
• Objective manifestations including rocking while standing/sitting, marching in place, and crossing/uncrossing legs
• Common adverse effect of antipsychotic medications
• Prevalence rates between 5-36.8% in patients on antipsychotics 2

Treatment Algorithm

First-Line Treatment:

1. Propranolol (non-selective beta-blocker)
   • Starting dose: 10-20 mg three times daily
   • Effective dose range: 30-80 mg/day 1
   • Mechanism: Lipophilic beta-blockers appear most consistently effective 2
   • Onset of action: Usually within 24 hours
   • Success rate: Complete remission in approximately 64% of cases 1

Second-Line Options (if propranolol fails or is contraindicated):

1. Benzodiazepines

   • Particularly useful when subjective distress persists 2
   • Lorazepam 1 mg orally/IV/IM (0.5 mg in elderly) 3
   • Provides symptomatic relief

2. Anticholinergic agents

   • Benztropine 1-2 mg orally
   • Note: Less consistently effective than propranolol 2

3. Dose reduction or switch antipsychotic medication

   • Consider switching to quetiapine or olanzapine which have lower risk of akathisia 4
   • Dose reduction of the causative antipsychotic if clinically feasible 4

Third-Line Options:

1. 5-HT2a antagonists

   • Mirtazapine 7.5-15 mg once daily has shown compelling evidence 5
   • Other options: trazodone, cyproheptadine, mianserin 5

2. Additional agents with some evidence:

   • Amantadine
   • Clonidine
   • Vitamin B6 (pyridoxine)

Special Considerations

Acute vs. Tardive Akathisia

• Acute akathisia: Occurs early in treatment, responds better to interventions
• Tardive akathisia: Develops after prolonged antipsychotic use, more resistant to treatment
  • May persist for years (mean 2.7 years) after discontinuation of causative agent 6
  • Propranolol has shown effectiveness in some cases of tardive akathisia 7
  • Reserpine and tetrabenazine may be more effective for tardive akathisia 6

Common Pitfalls

1. Misdiagnosis: Akathisia is often misinterpreted as psychotic agitation, anxiety, or worsening of psychiatric symptoms 4
2. Medication non-adherence: Akathisia is a common reason for antipsychotic non-compliance 4
3. Contraindications to propranolol: Avoid in patients with asthma, bradycardia, heart block, or severe heart failure 2
4. Monitoring: When using benzodiazepines, monitor vital signs, particularly respiratory rate, and assess sedation level every 15-30 minutes 3

Prevention Strategies

• Standardized titration of antipsychotics (start low, go slow)
• Use of newer atypical antipsychotics with lower risk profiles
• Early recognition and intervention at first signs of restlessness

By following this treatment algorithm and recognizing akathisia early, clinicians can effectively manage this distressing condition and improve medication adherence and quality of life for patients.