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 with lower risk, or adding propranolol (a beta-adrenergic blocking agent) as the most consistently effective pharmacological intervention. 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 impacts treatment adherence and quality of life

Treatment Algorithm

Step 1: Address the Causative Agent

1. Reduce the dose of the causative antipsychotic medication
2. Switch to an antipsychotic with lower akathisia risk:
   • Consider atypical antipsychotics such as quetiapine, olanzapine, or low-dose risperidone which have reduced risk of extrapyramidal symptoms 1
   • Clozapine, olanzapine, and quetiapine have lower akathisia rates compared to typical antipsychotics 2

Step 2: Pharmacological Interventions (if Step 1 is insufficient)

1. Beta-blockers:

   • Propranolol is the most consistently effective treatment for acute akathisia 3
   • Use with caution in patients with asthma, diabetes, or cardiovascular disease 1

2. Benzodiazepines:

   • Add if beta-blockers fail or if subjective distress persists 3
   • Provides symptomatic relief 4

3. Other options (if above treatments fail):

   • Anticholinergic agents (e.g., benztropine 1-2 mg daily) 1, 5
   • 5-HT2A antagonists (mirtazapine 7.5-15 mg once daily shows compelling evidence) 4
   • Amantadine (use with caution in renal impairment and monitor for abrupt discontinuation effects) 6, 3
   • Vitamin B6 5

Special Considerations

Monitoring

• Use standardized scales to assess akathisia before starting antipsychotics and during dosage titration 5
• Distinguish akathisia from psychotic agitation and restless legs syndrome 2
• Monitor for orthostatic hypotension in patients with cardiovascular disease when using beta-blockers 1

Risk Factors for Akathisia

• High dosage of antipsychotics
• History of akathisia in previous treatment
• Diabetes mellitus 2
• Elderly patients, very young patients, males, and patients on polypharmacy 1

Common Pitfalls

1. Misdiagnosis: Akathisia is often misdiagnosed as anxiety or agitation, leading to inappropriate treatment 7
2. Medication discontinuation: Abrupt discontinuation of amantadine may precipitate delirium, agitation, and other psychiatric symptoms 6
3. Polypharmacy risks: Combining medications may increase side effect burden 8
4. Treatment non-adherence: Untreated akathisia often leads to medication non-compliance due to its distressing nature 2

By following this structured approach and recognizing akathisia early, clinicians can effectively manage this distressing condition and improve patient outcomes and treatment adherence.