What are the dose recommendations for treating akathisia?

Dose Recommendations for Treatment of Akathisia

For antipsychotic-induced akathisia, propranolol at 30-80 mg/day is the first-line treatment with a 64% complete remission rate. 1, 2

First-Line Pharmacological Options

Beta-Blockers

• Propranolol (first choice):

  • Starting dose: 10-20 mg three times daily
  • Effective dose range: 30-80 mg/day
  • Maximum dose: 120 mg/day
  • Response typically occurs within 24 hours 2
  • Monitor for hypotension and bradycardia

• Metoprolol (alternative for patients with asthma/COPD):

  • Dose: 25-100 mg/day
  • Provides selective beta-1 blockade 3

Second-Line Options

Anticholinergics

• Benztropine:
  • Starting dose: 1-2 mg once or twice daily
  • Maximum dose: 6 mg/day
  • Particularly effective for acute dystonic reactions 4
  • Dosage must be individualized according to patient response

Benzodiazepines

• Lorazepam:
  • Dose: 0.5-2 mg as needed
  • Useful when subjective distress persists despite beta-blocker therapy 5

Serotonin Antagonists

• Mirtazapine:
  • Dose: 7.5-15 mg once daily
  • Response rate: 53.8% vs 7.7% for placebo 6
  • May be superior to propranolol in some cases (43.3% vs 30.0% response) 6
  • Particularly useful for patients with contraindications to beta-blockers
  • Common side effect: drowsiness

Treatment Algorithm

1. First step: Reduce dose of causative antipsychotic if clinically feasible 1

2. Second step: Consider switching to an antipsychotic with lower risk of akathisia (e.g., quetiapine or olanzapine) 1

3. Third step: If steps 1-2 are not possible or insufficient:

   • Start propranolol 10-20 mg three times daily
   • Titrate up to 30-80 mg/day as needed

4. Fourth step: If propranolol is contraindicated or ineffective:

   • Try metoprolol 25-100 mg/day (if contraindication is respiratory) OR
   • Add benztropine 1-2 mg twice daily OR
   • Try mirtazapine 7.5-15 mg at bedtime

5. Fifth step: For refractory cases, consider combination therapy:

   • Beta-blocker + anticholinergic
   • Beta-blocker + benzodiazepine

Important Clinical Considerations

• Akathisia is often misdiagnosed as psychotic agitation or anxiety, leading to inappropriate dose increases of the causative antipsychotic, which worsens the condition 1

• Monitor for side effects:

  • Beta-blockers: hypotension, bradycardia
  • Anticholinergics: dry mouth, blurred vision, urinary retention, constipation
  • Benzodiazepines: sedation, respiratory depression, dependence

• Akathisia is a common cause of medication non-adherence in patients taking antipsychotics 1

• Prevention strategies include slow titration of antipsychotics ("start low, go slow") and early recognition of symptoms 1

• For elderly patients or those with medical comorbidities, start with lower doses (e.g., propranolol 10 mg twice daily) and titrate more cautiously