What are the guidelines for managing akathisia?

Management of Akathisia

The first-line treatment for akathisia includes lowering the dosage of the causative antipsychotic medication, switching to another antipsychotic medication with lower risk (such as quetiapine), adding propranolol, or adding a benzodiazepine. 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: Modify Antipsychotic Therapy (First-Line)

• Dose reduction: Lower the dose of the causative antipsychotic if clinically feasible 1
• Medication switch: Consider switching to an antipsychotic with lower akathisia risk:
  • Quetiapine (initial dose: 12.5mg twice daily; maximum: 200mg twice daily) 1
  • Second-generation antipsychotics generally have lower risk than first-generation agents 1

Step 2: Add Pharmacological Interventions (B-CALM approach) 2

1. Beta-blockers (First choice):

   • Propranolol 10-30mg two to three times daily 3, 1
   • Use cautiously in patients with asthma, diabetes, or cardiovascular disease 1

2. Benzodiazepines:

   • Lorazepam 0.5-2mg as needed 1
   • Watch for paradoxical agitation (occurs in ~10% of patients) and risk of tolerance/dependence 1

3. Anticholinergics:

   • Benztropine 1-2mg daily (maximum 6mg daily) 4
   • Particularly useful for acute dystonic reactions 4
   • Initiate with low dose and increase gradually at 5-6 day intervals 4

4. Mirtazapine:

   • Low-dose (7.5-15mg once daily) has shown compelling evidence for efficacy 5
   • Acts through serotonin 5-HT2a receptor antagonism 5

Step 3: For Refractory Cases

• Consider amantadine 6, 7
• Clonidine may be effective in some cases 2, 7
• Vitamin B6, gabapentin, or pregabalin have shown promise but have insufficient evidence 2, 8

Special Considerations

Monitoring

• Regularly assess for abnormal movements during treatment using standardized scales like AIMS (Abnormal Involuntary Movement Scale) 1
• Monitor for orthostatic hypotension in patients with cardiovascular disease when using beta-blockers 1
• For patients on benztropine, monitor for anticholinergic side effects 4

High-Risk Populations

• Elderly patients: More sensitive to medication effects; use lower doses 1
• Parkinson's disease patients: Extremely sensitive to antipsychotic effects 1
  • Consider pimavanserin (first-line), clozapine (second-line), or quetiapine (third-line) 1

Types of Akathisia

• Acute akathisia: Typically resolves with treatment discontinuation 8
• Tardive/chronic akathisia: May persist after causative agent withdrawal and prove resistant to treatment 8

Pitfalls to Avoid

• Failing to recognize akathisia as a cause of agitation or non-adherence
• Mistaking akathisia for worsening psychosis or anxiety
• Increasing antipsychotic dose in response to akathisia (which can worsen symptoms)
• Overlooking akathisia in patients with motor disabilities or those under mechanical restraint 8
• Prolonged use of benzodiazepines can lead to tolerance and dependence 1

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