Management Guidelines for Akathisia
The first-line treatment for akathisia is lowering the dosage of the causative antipsychotic medication, switching to another antipsychotic with lower risk, or adding propranolol as a rescue medication. 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 for Akathisia
Step 1: Modify Antipsychotic Treatment (First-line)
- Reduce the dose of the causative antipsychotic if clinically feasible
- Switch to an antipsychotic less likely to cause akathisia:
- Consider quetiapine (initial dose: 12.5mg twice daily; maximum: 200mg twice daily) 2
- Avoid typical antipsychotics and higher-potency atypicals when possible
Step 2: Add Rescue Medication (First-line if antipsychotic modification not possible)
- Propranolol (non-selective beta-blocker): Most consistently effective treatment 3
- Starting dose: 10-20mg twice or three times daily
- May increase up to 80mg daily
- Contraindications: asthma, diabetes, cardiovascular disease 1
Step 3: Alternative Rescue Medications (Second-line)
Use the "B-CALM" approach for alternatives 4:
- B: Beta-blockers (propranolol, as above)
- C: Clonazepam or other benzodiazepines
- A: Anticholinergics (if parkinsonian symptoms also present)
- Benztropine: 1-2mg daily (maximum 6mg daily) 1
- L: cLonidine (alpha-2 adrenergic agonist)
- M: Mirtazapine
- Low dose (7.5-15mg once daily) has shown compelling evidence 5
Step 4: Additional Options (Third-line)
Special Considerations
Antipsychotic-Induced Akathisia
- Second-generation (atypical) antipsychotics generally have lower risk than first-generation (typical) agents 2
- Even atypicals like aripiprazole can cause akathisia 6
- Monitor closely during the first few days after starting therapy or increasing dose 1
SSRI-Induced Akathisia
- Similar management principles apply
- Consider dose reduction or switching to another antidepressant
High-Risk Populations
- Elderly patients (extremely sensitive to antipsychotic effects)
- Very young patients
- Males
- Patients with previous history of tremors
- Patients on polypharmacy
- Patients on higher doses of antipsychotics 1
Monitoring
- Use standardized assessment tools like the Barnes Akathisia Rating Scale
- Regularly assess for abnormal movements during treatment
- Monitor for orthostatic hypotension in patients with cardiovascular disease
- Watch for paradoxical agitation with benzodiazepines (occurs in about 10% of patients) 2
Prognosis
- Acute akathisia typically resolves upon treatment modification or with appropriate rescue medication
- Tardive and chronic akathisia may persist after the causative agent is withdrawn and can be more resistant to treatment 6
Akathisia should be addressed promptly as it significantly impacts patient comfort, treatment adherence, and can potentially increase risk of suicidal ideation in severe cases 2, 7.